his paper on tic doloreux.
"quis talia fando
temperet a lachrymis."
?
virgil.
perhaps, of all known torments, there is none that can be compared, either in intensity or duration, with that curious disease which has been called tic doloreux. like the term neuralgia, it is merely a hard word to express a violent pain in a nerve. conventionally, the term neuralgia, or nerve-pain, is generally used to express a case where the suffering is of a more or less diffused character. the term "tic" is more usually applied in cases where the seat of pain is found in some superficial nerve. neither term has much claim to the character of scientific nomenclature; they are merely equivalent to saying that we know very little of the matter. this obscurity, however, may be soon lessened, if not entirely cleared, by any one who will go to work in the way suggested by mr. abernethy's principles, and in which, to a certain point, they will conduct him. he must, however, recollect that the pain, though a most distressing symptom, is still a symptom, and not the disease which gives rise to it.
this disease teaches us how beneficently framed we are in relation to all around us; and how small a deviation from a healthy condition of our sensations converts all usual sources of pleasure into so many elements of agony. the breeze, of late so grateful and refreshing, may produce more suffering than would be excited by the most intensely-heated furnace. in other cases, the cool spring, or the most delicious fruit, become causes of79 torture. we should exceed all reasonable limits if we were to enumerate all the usual sources of pleasure which, in different cases, are converted into so many instruments of suffering.
tic doloreux is indeed a horrible malady; but one which, when properly considered, becomes very instructive. it admirably illustrates the views of abernethy; and how ready he was to concede all that examination of the views of others which modesty and common sense require, as well as how superior his own were, both in philosophical acumen and practical value; first examining the views of others, and finding them defective, he, with the true philosophical spirit which first discovers what is wrong—
"primus gradus est sapienti? falso intelligere,"
then proceeds to develop his own.
the nerves are the organs from which we receive all our impressions from without; and when their ordinary sensibility is thus morbidly augmented, we may be persuaded that there is something very wrong within.
the tic doloreux is one of the examples showing how cautious and circumspect, and how modest withal, abernethy was in advancing to his own comprehensive views of disease; and how entirely antithetical the method he pursued in arriving at them was to that which attempts to cut the knot of difficulty by gratuitous hypotheses.
when this disease first began to attract attention, it was suggested that it might be cured by the division of the nerve. the phenomena of the nervous system afforded abundant grounds for mistrusting the soundness of this view. the tendency, however, to confound the more salient symptom of a disease with its intrinsic nature, caused such phenomena to be overlooked or little considered; and the consequence was, that where the nerve was divided, the treatment was sometimes entirely confined to that proceeding.
in the end, the operation disappointed expectation; and that which careful reasoning might have predicted as probable, was left to be determined by experiment, in some cases, circumstances80 concurred to produce temporary relief; but on the whole the operation was a failure.
in the case he here published, abernethy removed a little bit of nerve from a lady's finger. as she had suffered severely, and he was anxious to give her more permanent relief, he did not rest satisfied with merely dividing the nerve. for about nine months the lady was in comparative ease; but then the sensation returned. he remarks on the interest attached to this return of sensation, and observes on the analogy it suggests between the supply of blood, and that of nervous power. for if the vessels conveying the former be tied or obstructed, the supply is gradually restored through collateral channels. the return of the nervous functions, after the removal of a portion of the nerve, seemed to favour that view of the nervous system which regarded as the proximate cause of the phenomena some subtle principle or other, like electricity or magnetism, or some analogous power, of which the nerves might be the conductors.
perhaps the most interesting fact of this case, however, was the significant bearing it had on those views which he was beginning to deduce from a multitude of other sources. the fact being, that when the lady died, which she did about four years afterwards, she died of disordered digestive organs. showing, therefore, at least, the coincidence of the most severe form of nervous disturbance with disorder of these important functions.
we shall see, by and by, that mr. abernethy made this and other cases the instruments of much future good; but as we shall not be able to digress from that summary of our obligations, which we shall then be employed in taking, we will add a few words here in aid of removing that difficulty which some people have in understanding how such dreadful pain can result from any organ in the interior of the body, where no pain is felt at all. in order to do this, it is only necessary to have a clear general notion of the nervous system. if you could take away everything but the nerves, you would have the brain, spinal marrow, and certain knot-like pieces of nervous substance (ganglions, as we term them) from which myriads of cords proceeded, varying in size from the smallest imaginable filaments up to moderate81 sized cords; the ends of the delicate filaments terminating in the various organs and on the surface of the body; millions of messengers of the most extreme sensibility, by which impressions are telegraphed with the swiftness of lightning between all parts of the body. there is, however, a habit or rule which is ordinarily observed, and that is one of the most curious things in the whole range of physiology—namely, that the immediate cause of our recognition of sensation is never in the part itself, but the action is constantly transferred to the extremity of the nerve. when you strike the ulnar nerve at the elbow (popularly termed, sometimes, the funny-bone), you feel it in the fingers to which its branches are distributed.
if you place your finger in cold or warm water, the action that makes you feel it is in the brain; and we infer this, because if we divide the communication between the brain and the finger, you no longer feel the sensation. now, bearing this in mind, you easily understand how anything disturbing the nerves of any internal organ may produce pain in some distant branch; and that this is really so, many cases of tic doloreux have furnished conclusive and triumphant proofs. now, as to why it should be seated in this or that particular site, is a question of extreme difficulty; as also in what organ the primary disturbance is seated, supposing it to have been in any of them. the former, i believe, is a question we have yet been unable to solve; the latter may usually be accomplished, if sufficient pains be taken.
abernethy, in his lectures on this subject, when observing on the inefficiency of this division of the nerve—which was ministering to effects only—was accustomed to remark, with that peculiar archness of expression which his pupils must so well remember: "i wonder that it never entered into the head of some wise booby or other to divide the nerve going to a gouty man's toe." this was a very characteristic mode of terminating a discussion of any point which he wished to impress on the memory of the pupil.
82
section.
of his paper on occasional consequences of bleeding.
in these days of improved statistical inquiry, it would be a curious document which should give us the comparative number of persons who are now bled, and that of only fifty years ago; and whilst it would present very instructive data as to the progress of medical science, it would give also some significant hints as to the relations of fashionable remedies. first, almost every barber was a bleeder; and within my own recollection, a lady, who for any serious ailment consulted the most eminent physician in the neighbourhood in which she lived, would allow no one to bleed her but the barber.
formerly, multitudes of people lost a little blood every "spring and fall." accidents of all kinds afforded a fine opportunity for bleeding. the papers announced accidents generally by the usual—"it is with regret that we learn that sir harry —— was thrown from his horse in the park. it was feared that the honourable baronet had sustained serious injury; but, fortunately, mr. sharpe was on the spot, so that the patient was immediately bled. he was conveyed home, and we rejoice to hear that he is doing well. the accident, which it had been feared was a fracture, proved to be only a 'dislocation.'"
the questions in regard to bleeding were said to be—who, when, and how much (quis, quando, quantum?); but, to our minds, aret?us has a better saying: "when bleeding is required, there is need of deliberation (cum sanguinem detrahere oportet, deliberatione indiget)." we like this better; because, in addition to the little words quoted above, it suggests another, more important than either—namely, cur? why—on many occasions, a favourite inquiry of abernethy's.
we recollect a surgeon being called to a gentleman who was taken ill suddenly, and he found two or three servants and the83 medical attendant struggling very vigorously with the patient. whilst this was continuing, the first question put to the surgeon by the medical attendant was:
"shall i bleed him, sir?"
"why should you desire to bleed him?"
"oh! exactly; you prefer cupping?"
"why should he be cupped?"
"then shall i apply some leeches?"
this, too, was declined; in short, it never seemed to have occurred that neither might be necessary, still less that either might therefore do mischief.
it is the most curious thing to see the force of a well-grown conventionalism. as long as it led to moderately bleeding plethoric baronets in recent accidents, no great harm would have been done; but the frequency in other cases, in which bleeding was instituted with "apparent impunity," was too commonly construed into "bleeding with advantage," until the practice became so indiscriminate as to be extensively injurious. now, comparatively, few persons are bled; and some few years ago i had a curious illustration of it.
in a large institution, relieving several thousand patients annually, and in which, a very few years before, scarcely a day passed without several persons having been bled; nearly a month elapsed without a single bleeding having been prescribed by either of the three medical officers.
no doubt many persons are still bled without any very satisfactory reason; but we believe that the abuse of bleeding is much diminished, and that the practice is much more discriminate and judicious. from this, and perhaps other causes, a very important class of cases which engaged the attention of abernethy, as it had that of hunter before him, is become comparatively infrequent. when bleeding, however, was practised, with as little idea of its importance as some other of the barber-surgeon's ministrations, on all sorts of people, and in all sorts of disturbed states of health, and probably with no attention at all to the principles which should alike guide the treatment of the largest or the smallest wound; this little operation was frequently followed84 by inflammation of the vein, nerve, or other contiguous structures. these cases were, most of them, more or less serious, often dangerous, and occasionally fatal.
taking up the subject where it had been left by mr. hunter, abernethy refers to the cases published in the two volumes of the "medical communications," by mr. colly of torrington, and by mr. wilson, and then proceeds to give some of his own. it is in this paper that he first moots two questions which have since grown into importance, by an extension of some of the practices to which they refer. we allude to the division of fasci?, and tendinous structures, and also of nerves in states of disease or disorder.
in many cases we see, in the application of such measures, how much that clear and quick-sighted discrimination is required which so eminently distinguished abernethy. he, however, only mooted these questions at that time; for he observes that he had not had sufficient experience to give an opinion. the chief value of the paper now is, the good sense with which it inculcates a more careful and cleanly performance of bleeding; a more scientific treatment of the puncture, by neatly bringing its edges into apposition, and by keeping the arm quiet until it has healed. neglect of these cautions in disordered states of constitution, had no doubt been not infrequently accessory to the production of some of the serious consequences against which it is the object of this paper to guard. i need scarcely observe that the whole subject is important, and should be thoroughly studied by the young surgeon.
in 1793, abernethy, by his writings and his lectures, seems to have created a general impression that he was a man of no ordinary talent. his papers on animal matter, and still more his essay on the functions of the skin and lungs, had shown that he was no longer to be regarded merely in the light of a rising surgeon, but as one laying claim to the additional distinction of a philosophical physiologist. the subject (of the skin and lungs) had engaged the attention of b?erhaave a long time before; cruikshank also, and other very able men, had followed in the same wake of investigation; therefore there was an opportunity85 of that test which comparison alone affords. abernethy was, in fact, regarded at this time more in the light of a rising man, than merely a promising surgeon. he now moved from st. mary axe (as i am informed), and took a house in st. mildred's court, in the poultry.
sir charles blicke had moved to billiter square. i find, by the rate-books, which mr. b. l. jones was so good as to inspect for me, that this was in april, 1793. he could hardly fail at this time to have had a very acceptable portion of practice, although we apprehend it was not as yet extensive. his reputation was, however, fast increasing, which the attention paid to his opinion at the hospital at this time must have materially accelerated.
certainly not later than 1795, there were very few cases of doubt or difficulty, in which (independently of that participation in the consultation at the hospital common to all the medical officers) there was not especial value and influence attached to his opinion; and i have heard a pupil of that day assert, that in cases of real doubt and difficulty, there was nothing more beautiful in itself, nor more characteristic of abernethy, than the masterly way in which he would analyze a case, bring the practical points before his colleagues, and at the same time suggest the course he preferred. as, from his other occupations, it would often happen that some consultation might be pending whilst he was engaged at the theatre or in the museum, it would often happen that a consultation would terminate for the time by some one observing: "well, we will see what mr. abernethy says on the subject."
in 1796, he became a fellow of the royal society, his old preceptor, sir william blizard, being one of those who signed the proposal for his election. he only contributed one paper after this to the "philosophical transactions." after his death, the duke of sussex pronounced a very well-deserved eulogium, of which a copy will be found in another part of this volume. he had not been idle, however; but, in 1797, published the third part of the "physiological essays," which we will consider in the next place.
