a course of lectures on pain, and the therapeutic influence of mechanical and physiological rest in...

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No. 1984. SEPTEMBER 7, 1861. A Course of Lectures ON PAI N, AND THE THERAPEUTIC INFLUENCE OF MECHANICAL AND PHYSIOLOGICAL REST IN ACCIDENTS & SURGICAL DISEASES. Delivered in the Theatre of the Royal College of Surgeons, BY JOHN HILTON, ESQ., F.R.S., SURGEON TO GUY’S HOSPITAL, PROFESSOR OF ANATOMY AND SURGERY TO THE ROYAL COLLEGE OF SURGEONS, LECTURE III.-PART II. Illustrations from Nerves of Lower Extremity. IN the lower extremity we discover the same law of nervous distribution as in the arm. For example, the anterior crural nerve supplies all the muscles which we employ in the first effort of progression; we flex the thigh, we extend the knee, and we slightly evert the leg, and all the muscles employed for those purposes are supplied by the anterior crural nerve-the psoas, the iliacus, pectineus, crureus, subcrureus, the two vasti, the rectus, and sartorius muscles. All these muscles are sup- plied by the anterior crural nerve, and so is the skin over their insertion, as well as the joints which those muscles move. We are all acquainted with those numerous cutaneous nerves (branches of the anterior crural) distributed over the thigh, in- cluding the external cutaneous nerve, which supply the skin as far as the knee-joint, corresponding with the subjacent distri- bution of the anterior crural nerve to the various muscles. But I must select from these various cutaneous nerves the long saphenous, which pursues a peculiar course, and runs ahead (seemingly, at first thought, without purpose) of all the other nerves downwards as far as the ankle-joint and the side of the foot. I say, at first sight it would appear extraordinary that this long saphenous nerve should run away from its comrades, and apparently from its proper muscular and cutaneous associa- tion, and proceed as far as the inner side of the foot; but when we come to examine this drawing the thing is explained. FIG. 17. , a, Sartorius muscle divided in the lower third of the thigh, and turned downwards, resting upon the blades of forceps; q b, Semi-tendinosus; c, Glacilis muscle; d, Fascia ofleg with all these muscles attached to it; e, Long saphenous nerve divided. Here is a sketch, taken from a dissection of the inner side oj the knee, made purposely for me. The sartorius muscle has been divided, and its lower portion turned downwards. This muscle is most intimately and largely attached to the fascia oj the leg, in truth, the fascia of this portion of the limb must be considered as part of the insertion of the eartorins, just as the fascia of the forearm is to be considered as part of the insertion of the biceps muscle; so that not only is the sartorius supplied by the anterior crural nerve, but, as you will observe, the long insertion, extending down the leg some considerable distance, even as far as the ankle-joint, where it is blended with the fascia over the foot on the inner side of the inner malleolns, receives its nervous supply from the same source. Thus is ex- plained why this long saphenous nerve, which is derived from the anterior crural, should thrust itself through the fascia of the thigh, become subcutaneous, and then follow the course of the skin as far as the inner side of the ankle joint, and some- times as far as the inner side of the dorsal aspect of the foot, thus following the fascia. At first sight it appears a deviation from the natural order to find this anterior crural sending along branches to the leg as far as the foot; yet when you come to examine this fascial association, you see that it is only a carry. ing out of the principle, that the same nerve which supplies the muscle supplies the skin over the insertion of the muscle- the sartorius having a long fascial insertion as far as the point I have already indicated, and requiring an equally long nervous supply. The anterior crural nerve sends branches also to the hip- joint. I have here a little sketch of the nerves of the hip. joint of Mr. Durham, which has been taken from his notes of FIG. 18. Sketch of nerves supplying the anterior and inner parts of the capsular ligament of the hip-joint. a, Filaments from the anterior crural nerve. b, Fila- ments from the obturator nerve. the various opportunities which he has had of dissecting the nerves going to the capsular ligament of the hip-joint. I wish you to understand that these articular nerves are not copied directly from dissections, but are sketches made from different nerves, and grouped together to convey to you the idea of the supply of nerves to the hip-joint, although not with that pre- cision of anatomy which, no doubt, is always desirable, and especially so within this College. We see filaments of the an- terior crural nerve traced to the anterior part of the capsular ligament of the hip-joint; and it may be traced to the muscles of the thigh, as well as to the capsular ligament of the knee- joint. I have here also a sketch of another nerve traced to the knee-joint (copied from Mr. Swan’s book)-a portion of the great sciatic nerve, sending branches underneath the fascia to the capsular ligament, and, no doubt, reaching the interior of the joint. Here is seen a recurrent branch going to the inferior part of the knee-joint. The same law attaches itself to the distribution of the sciatic nerve, the details of which I will not trouble you with. But to return to the anterior crural. We see that this nerve supplies the joints which its muscles move, the anterior part of the hip-joint, and a portion of the knee-joint; and it supplies the skin over the whole of the muscles of the thigh, as well as the skin on the inner side of the leg, as low down as the extension of the fascia which is attached to the sar- torius muscle.

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No. 1984.

SEPTEMBER 7, 1861.

A Course of LecturesON

PAI N,AND THE

THERAPEUTIC INFLUENCE OF MECHANICALAND PHYSIOLOGICAL REST

IN

ACCIDENTS & SURGICAL DISEASES.

Delivered in the Theatre of the Royal College of Surgeons,

BY JOHN HILTON, ESQ., F.R.S.,SURGEON TO GUY’S HOSPITAL,

PROFESSOR OF ANATOMY AND SURGERY TO THE ROYAL COLLEGE OF SURGEONS,

LECTURE III.-PART II.

Illustrations from Nerves of Lower Extremity.IN the lower extremity we discover the same law of nervous

distribution as in the arm. For example, the anterior cruralnerve supplies all the muscles which we employ in the firsteffort of progression; we flex the thigh, we extend the knee,and we slightly evert the leg, and all the muscles employed forthose purposes are supplied by the anterior crural nerve-thepsoas, the iliacus, pectineus, crureus, subcrureus, the two vasti,the rectus, and sartorius muscles. All these muscles are sup-plied by the anterior crural nerve, and so is the skin over theirinsertion, as well as the joints which those muscles move.We are all acquainted with those numerous cutaneous nerves(branches of the anterior crural) distributed over the thigh, in-cluding the external cutaneous nerve, which supply the skin asfar as the knee-joint, corresponding with the subjacent distri-bution of the anterior crural nerve to the various muscles.But I must select from these various cutaneous nerves the longsaphenous, which pursues a peculiar course, and runs ahead(seemingly, at first thought, without purpose) of all the othernerves downwards as far as the ankle-joint and the side of thefoot. I say, at first sight it would appear extraordinary thatthis long saphenous nerve should run away from its comrades,and apparently from its proper muscular and cutaneous associa-tion, and proceed as far as the inner side of the foot; but whenwe come to examine this drawing the thing is explained.

FIG. 17. ,

a, Sartorius muscle divided in the lower third of the thigh,and turned downwards, resting upon the blades of forceps; qb, Semi-tendinosus; c, Glacilis muscle; d, Fascia ofleg withall these muscles attached to it; e, Long saphenous nervedivided.

Here is a sketch, taken from a dissection of the inner side ojthe knee, made purposely for me. The sartorius muscle hasbeen divided, and its lower portion turned downwards. Thismuscle is most intimately and largely attached to the fascia ojthe leg, in truth, the fascia of this portion of the limb must beconsidered as part of the insertion of the eartorins, just as thefascia of the forearm is to be considered as part of the insertionof the biceps muscle; so that not only is the sartorius suppliedby the anterior crural nerve, but, as you will observe, the longinsertion, extending down the leg some considerable distance,even as far as the ankle-joint, where it is blended with the

fascia over the foot on the inner side of the inner malleolns,receives its nervous supply from the same source. Thus is ex-

plained why this long saphenous nerve, which is derived fromthe anterior crural, should thrust itself through the fascia ofthe thigh, become subcutaneous, and then follow the courseof the skin as far as the inner side of the ankle joint, and some-times as far as the inner side of the dorsal aspect of the foot,thus following the fascia. At first sight it appears a deviation

’ from the natural order to find this anterior crural sending alongbranches to the leg as far as the foot; yet when you come toexamine this fascial association, you see that it is only a carry.ing out of the principle, that the same nerve which suppliesthe muscle supplies the skin over the insertion of the muscle-the sartorius having a long fascial insertion as far as the point Ihave already indicated, and requiring an equally long nervoussupply.The anterior crural nerve sends branches also to the hip-

joint. I have here a little sketch of the nerves of the hip.joint of Mr. Durham, which has been taken from his notes of

FIG. 18.

Sketch of nerves supplying the anterior and inner partsof the capsular ligament of the hip-joint.

a, Filaments from the anterior crural nerve. b, Fila-ments from the obturator nerve.

the various opportunities which he has had of dissecting thenerves going to the capsular ligament of the hip-joint. I wishyou to understand that these articular nerves are not copieddirectly from dissections, but are sketches made from differentnerves, and grouped together to convey to you the idea of thesupply of nerves to the hip-joint, although not with that pre-cision of anatomy which, no doubt, is always desirable, andespecially so within this College. We see filaments of the an-terior crural nerve traced to the anterior part of the capsularligament of the hip-joint; and it may be traced to the musclesof the thigh, as well as to the capsular ligament of the knee-joint.

I have here also a sketch of another nerve traced to theknee-joint (copied from Mr. Swan’s book)-a portion of thegreat sciatic nerve, sending branches underneath the fascia tothe capsular ligament, and, no doubt, reaching the interior ofthe joint. Here is seen a recurrent branch going to the inferiorpart of the knee-joint. The same law attaches itself to thedistribution of the sciatic nerve, the details of which I will nottrouble you with.But to return to the anterior crural. We see that this

nerve supplies the joints which its muscles move, the anteriorpart of the hip-joint, and a portion of the knee-joint; and itsupplies the skin over the whole of the muscles of the thigh,as well as the skin on the inner side of the leg, as low downas the extension of the fascia which is attached to the sar-torius muscle.

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It is important, in tracing the nerves in this way, to fix uponthem, as far as we can, some useful reference, so that we maynot only bear them in mind, but see the practical application Iof the subject. Now, we know that the long saphenous nervefollows the course of the saphena major vein; and this is, nodoubt, the explanation of patients experiencing so much painin this neighbourhood when these veins are dilated and pressupon portions of the nerve. So again ulcerations, on the lowerand inner part of the leg, although small, are sometimes ex-quisitely painful-irritable, as we term them; and on someoccasions I have been under the necessity of dividing the nerve ein the ulcer, and that has led to its rapid healing-a point inrespect of which I have addressed you two or three times be-fore. The pain in the leg thus experienced is most manifestwhen the patient is standing, when all these veins are full ofblood, and thereby encroaching upon the nerves; but if the

leg be lifted up, and the bloodvessels so emptied, the pain isquickly relieved. It is pressure upon the nerve that causesthe pain under those circumstances. I have very often recom-mended (with great advantage to the patients) elderly per-sons suffering from large veins, with or without sore legs, toraise the lower half of the bed on which they sleep so as toplace the legs a little higher than the pelvis, so that they maylie up hill; the veins are thus empty nearly all the night, andthe result of that is to remove the pressure; and if the patientsare in bed half their lives, Nature has an opportunity of re-pairing the injuries that have been inflicted. I have knownmany persons by that simple circumstance to live in great com-fort and freedom from the repetition of these small ulcers,simply by having the lower half of the bed slightly elevated,so that whether the patient be asleep or awake, the legs arealways lying on a slightly inclined plane, and the venous bloodruns down easily to the neighbourhood of the thigh, where itenters freely into the general circulation.

ON THE UNCERTAINTY OF THE SPUTUMAS A DIAGNOSTIC FEATURE

IN PNEUMONIA.

BY THOMAS WILLIAMS, M.D. (LOND.), F.R.S.,PHYSICIAN TO THE SWANSEA INFIRMARY.

THE following cases are highly instructive. They convey, ,,

in a practical sense, a lesson of great value. It constantlyoccurs that a case of true pneumonia passes through all itsstages to recovery without once exciting the suspicion of thepractitioner as to its real nature. It is allowed to pass underthe vague name of "influenza," "feverishness," "cold," or"slight fever," &c. There is no expectoration; there is no

cough; there is no pain in the side; no obvious symptom ispresent by which the attention is invited to the chest. If a

stethoscopic examination is made, it is done hurriedly andcarelessly, and the case is dismissed as something which it isnot. These oversights are committed because students aretaught by nearly all standard authorities to lay faith in themost variable rather than the least variable symptoms, assigns of the disease.Another class of cases mislead by the hasmoptysio character

presented bv the snutum. Pure blood, of a bright scarlet

colour, in portions of variable amount, is mixed up with thesputum, the latter being colourless as in bronchitis. Able andcautious practitioners have condemned such cases as phthisical,and therefore fatal, in which the most complete and lastingrecovery has afterwards taken place. Fallacy in this directionis painful in the extreme. The verdict of death is pronouncedover those whose life is in no danger. Character and confi-dence are destroyed, and the medical attendant becomes thegreatest sufferer.

In the description of the following cases the strictest brevitywill be observed. The fact that a pneumonic consolidationof the lung existed has been carefully determined in each in-stance by auscultatory examination. To mention the familiarsigns of such consolidation were to occupy space unnecessarily;the object being to show how extremely uncertain, variable,and untrustworthy the sputum-the expectoration-is as a

symptom of pneumonia,

CASE I.-T. M-, aged thirty-eight; a fine, healthy, tall,muscular man. Consolidation of middle and inferior lobes ofright lung. Expectoration considerable in quantity for six

weeks, blended twice or thrice a day with teaspoonfuls andtablespoonfuls of bright scarlet blood; rest of sputum not

rusty nor viscid, but muco-purulent. Was very ill for twomonths; returned to his employment in three months. Threeyears have elapsed since the date of this attack; the man isnow quite well; the lungs are perfectly free from any evidenceof tubercle. The wife and friends have never forgiven me forhaving said at the time of the attack that he was consump-tive and would not recover.

CASE 2.-Mr. S-, aged forty, a teetotaller, a broad-chested,firmly-built man, a baker and grocer. Nearly the whole of theright lung hepatized. For three weeks was very ill, without anycough or expectoration whatever. Suddenly a cough occurred." Spitting" of frothy mucus followed. In two days the expec-toration amounted to a pint; in four days, to a quart in quan-tity. It now became most offensive and disgusting to thesmell. For a month it continued at this rate, and of thisquality. It gradually ceased. In three months the man was

quite recovered. In this case the first two stages of engorge-ment and red hepatization were marked by no expectorationwhatever. The third stage, that of grey hepatization, wasstrikingly indicated by the characteristic sputa.CASE 3.-J. W-, aged eighteen. Fine crepitation; dull

percussion-note; bronchophony under left scapula; rusty ex-pectoration copious. Was quite well in nine days.

CASE 4.-Mr. J-, aged forty-six. Pneumonic signs veryclear under and around the left scapula; sharp heat of surface;hurried breathing. Was ill for fourteen days. Not the slightestparticle of anything coughed up from first to last..No drycough.CASE 5. -The Rev. Mr. -’s son, aged seventeen. Very

distinct pneumonic signs over a small space of the right lungbetween the two scapulae. Was ill twelve days. Threw uponce or twice only by cough a slight quantity of clear whitemucus. No other expectoration whatever.CASE 6.-W. F-, aged thirty. Pneumonia of middle and

back portion of the inferior lobes of the right lung. Expec-torated large quantities of characteristic rusty sputa. Quitewell in sixteen days.CASE ’7.-C. M- aged twenty-five. Pneumonia of middle

and lower parts of the left lung. Signs unquestionably dis-tinct. Was ill for about a fortnight. No expectoration what-ever during any stage.CASE 8.-D. J-, aged twenty. Fine crepitation ; tubular

breathing; bronchophony around the angle of the right scapula,Recovered in seventeen days. Very slight clear mucous ex-pectoration during a day or two.

CASE 9.-T. P-, aged thirty-five. Pneumonia of the

right lung. Signs audible round to the front under the rightbreast. Was ill for three weeks. Nothing that could becalled expectoration at any time.CASE 10.-T. W-, aged twelve. Consolidation of the

back and side of the right lung; slight pain in side; slight drycough; no expectoration whatever. Was quite well in thirteendays.CASE 11.-Mrs. D-. Pneumonia of the left side; signs

very clear under the breast and round under the axilla. Hada little cough, by which mucus only was brought up. Saw a

slight streak of blood once only. Recovered in seventeen,days.CASE 12.-A. B-, a strong working man. Pneumonia of

right lung extensive. Rusty sputa thrown up in copious amountfor seven days. Recovery complete and rapid. Returned towork in three weeks.

CASE 13. -Master D-, a boy in school, aged fifteen. Signsof pneumonic consolidation very clear round right scapula; nopain; no expectoration whatever. Quite well in fifteen days.

CASE 14.-Capt. F-, aged fifty-fivp, a very stout man.Attended by the late Dr. Rowland and myself. Fine crepita-tion of bases of both lungs. Percussion-note dull. Was ill a

. fortnight, when he died in a typhoid condition. Never had theslightest expectoration.CASE 15.-A. F-, aged fourteen, a boy in school. Slight

, pneumonia of right lung; had no cough; spat up nothing what-ever. Recovered in ten days.