The dialectic of motion and rest: A historical view on the management of joint pain

“ Thus, everywhere, through all realms, do the opposite principles of Rest and Motion depend upon and reciprocally empower each other. In every act, mechanical, mental, social, must both take part and consent together; and upon the perfection of this consent depends the quality of the action. ”

“ Motion or change, and identity or rest, are the first and second secrets of nature: Motion and Rest. [203] The whole code of her laws may be written on the thumb-nail, or the signet of a ring. ”

“ When I feel any suffering, I have only to execute some motion, to feel it less. Motion is the best of anæsthetics. It disperses at a stroke all the little uneasinesses that accompany even the normal working of our organs, and which we experience when we are occupied only with feeling ourselves live. When we make an energetic effort, we are nearly insensible to pain as long as it lasts. When I am at rest, a blow on the shoulder will hurt me. In the ardor of sport, in the excitement of a violent exercise, the roughest shock will hardly be felt. ”

“ Pains from excess, and from defect of motion. No pain is felt during vehement voluntary exertion; as in cold fits of ague, labour-pains, strangury, tenesmus, vomiting, restlessness in fevers, convulsion of a wounded muscle. 3. Of holding the breath and screaming in pain; why swine and dogs cry out in pain, and not sheep and horses. Of grinning and biting in pain; why mad animals bite others. 4. Epileptic convulsions explained, why the fits begin with quivering of the under jaw, biting the tongue, and setting the teeth ”

“ From walking arise pains of the sides, of the back, of the loins, and of the hip-joint, and disorder of the respiration has often been from the same cause, for, after excesses of wine and flatulent food, pains shoot to the loins and hips, accompanied with dysuria. ”

“ The symptoms are referred to the joint, because it is there that the muscles are inserted and drag on the perichondrium when movement occurs; swelling is most marked in the vicinity of the joint, and it may be added to by effusion into the synovial cavity. The baby, usually under six months, is noticed to be feverish and fretful and to cry when touched. The mother discovers that the pain is caused by moving a particular limb, usually the arm, as the humerus, radius, and ulna are the bones most commonly affected ”

“ This can only be explained from conceiving that the power of motion, whatever it is, or wherever it resides, and which is capable of being exhausted by fatigue, and accumulated in rest, is now less expended, whilst one half of the body is capable of receiving its usual proportion of it, and is hence derived with greater ease or in greater abundance into the limbs, which remain unaffected. ”

“ On the contrary, where there has been less fibrous contraction than usual for a certain time, the sensorial power or spirit of animation becomes accumulated in the inactive part of the system. Hence vigour succeeds rest, and hence the propensity to action of all our organs of sense and muscles is in a state of perpetual fluctuation. The irritability for instance of the retina, that is, its quantity of sensorial power, varies every moment according to the brightness or obscurity of the object last beheld compared with the present one. ”

“ Injuries of all kinds are the more frequent causes of hip lameness. In such cases, lameness may result directly and resolution be prompt, or the claudication become aggravated in time, due to muscular atrophy or degenerative changes affecting the hip joint or nerves. Rheumatism or metastatic infection may be the cause of hip lameness as well as affections of the pelvic bones, lumbar and sacral vertebrae. Hip lameness may also be provoked by melanotic or other tumors.
In the diagnosis of hip lameness, one is guided in a general way by the character of the impediment manifested. ”

“ Abnormal attitudes of the limb occur earlier, and are more pronounced in cases in which pain and other irritative symptoms of articular disease are well marked, and are best illustrated by the attitudes assumed in disease of the hip. They are due to reflex or involuntary contraction of the muscles acting on the joint, with the object of placing it in the attitude of greatest ease; they also disappear under anæsthesia. With the lapse of time they not only become exaggerated, but may become permanent from ankylosis or from contracture of the soft parts round the joint. ”

“ Let the student, then, shun an excited and spasmodic tension of brain, and he will gain more while expending less. It is not toil, it is morbid excitement, that kills; and morbid excitement in constant connection with high mental endeavor is, of all modes and associations of excitement, the most disastrous. Study as the grass grows, and your old age—and its laurels—shall be green.
Already, however, we are trenching upon that more intimate relationship of the great opposites under consideration which has been designated Rest in Motion. ”

“ In the light of our vast experience at the Invalids' Hotel and Surgical Institute, we feel that we cannot too strongly urge the employment of a suitable apparatus for supporting the hip-joint, giving it perfect rest, and enabling the patient to exercise and get the outdoor air. As much of the pain in this disease is due to the pressure of the head of the femur, or thigh-bone, in the acetabulum, or socket, steadily-applied mechanical extension, to relieve the inflamed and sensitive joint of the pressure, is of the greatest importance. ”

“ Instead of depleting, we, by proper constitutional treatment, strengthen and fortify the system. We do not confine the patient in bed, but permit him to go around and take all necessary exercise. We adjust an ingeniously devised and perfectly fitting appliance or apparatus, by which a gentle extension of the limb is maintained, thereby relieving the tension of the muscles, and preventing the friction and wearing of the inflamed surfaces of the joint, which, without the use of our new and improved appliance, are a source of constant irritation. ”

“ Quite needless to say, variety is more important for the ailing than the well.
Pain Psychic Conditions.—Pain after operation is an extremely common symptom and often causes much disturbance. Every surgeon knows how {763} individual are patients in this respect, and how much depends on the personal reaction to pain. There are men and women who have very serious lesions, from which much pain might be expected, who complain very little. There are, on the other hand, many men as well as women who complain exaggeratedly after even trifling surgical intervention. ”

“ I always thought gout meant large lumps, and swellings of the joints.”
“So it does,” said Mrs Jefferson, with an involuntary glance at the moist and crimson sufferer on her right. “But my form of it is different. It is much worse, but no one sympathises with me because it doesn’t look so bad as the other gout.”
“It is not often that people do sympathise with illness,” said the beautiful woman. “When we ourselves are well, we think suffering can’t be so very great after all, and when we are ill we are quite sure no one else has to bear so much pain. Human nature is essentially selfish. ”

“ In disease of the hip-joint pain is felt, not in the hip, but, in the early stage of the disease, at the knee. This also depends on nervous communication. The most dreadful consequences daily occur from an ignorance of this single fact. ”

“ But when we have to rely upon one sense alone, we are sometimes liable to curious deceptions. This is the case with some of the feelings of touch. In hip-joint disease the pain is often referred to the knee, while it is really in the hip. This is because the nerve which conveys sensation from the knee, also sends a branch to the hip-joint. The experiences of those who have lost a limb are familiar. ”

“ Epileptic fits generally commence with setting the teeth, by which means the tongue is frequently wounded; and with rolling the eyeballs in every kind of direction; for the muscles which suspend the jaw, as well as those which move the eyes, are in perpetual motion during our waking hours; and yet continue subservient to volition; hence their more facile and forcible actions for the purpose of relieving pain by the exhaustion of sensorial power. ”

“ When stiff and sore and scarred
I take away my hand
From leaning on it hard
In grass and sand,
The hurt is not enough:
I long for weight and strength
To feel the earth as rough
To all my length. ”

“ When a sensation has the power of exciting a given muscular action, the idea of that sensation, if sufficiently vivid, will excite it likewise. 3. The idea of the sensation which excites an automatic action of the muscles, persists during the action, and becomes associated with it by contiguity, in such a manner as to be itself, in its turn, excited by any vividly recalled idea of the muscular act. 4. The following is what takes place in voluntary motion. The idea of the end we desire, excites by association the idea of the muscular act which would procure it for us. ”

“ Volition is said in Section V. to bear the same analogy to desire and aversion, which sensation does to pleasure and pain. And hence that, when desire or aversion produces any action of the muscular fibres, or of the organs of sense, they are termed volition; and the actions produced in consequence are termed voluntary actions. Whence it appears, that motions of our muscles or ideas may be produced in consequence of desire or aversion without our having the power to prevent them, and yet these motions may be termed voluntary, according to our definition of the word ”

“ The expenditure in this case is made for saving, and takes place, we think, because the first motion in the face of pain being a movement of conservation and concentration on self, is also a tendency to save the force which is felt to he diminishing—we retire from the pain, and try to recover ourselves. The first stage of pain does not last long, for the reaction begins at once. While the will can consent to pleasure, it can not consent to pain. It defends itself, it struggles, against it. ”

“ I have often observed that while the limb to which the whole attention has been directed in performing some movement has been steadied, the other limbs become violently agitated.
In another class of cases the movements are comparatively slight when the part is at rest, but when a motion is attempted the disorder of the muscles is so much increased that it is almost impossible for the act to be completed. The patient is told to pick up some small object: he throws the hand out toward it, and it is jerked away before he can grasp it. ”

“ In these affections of joints the pain, indeed, is seldom constant: the patient’s rest is not broken; there are none of the violent spasms during sleep, which attend upon certain alterations of structure. The pain is equally complained of when the part is touched with the utmost gentleness, or when a thorough and searching examination is made, when the joint is freely moved, and the articulating surfaces of the bones are forcibly squeezed against each other. The pinching of the skin causes pain. There is seldom throbbing, or heat, or swelling ”

“ Fracture of the head of the femur occurs sometimes, especially in puppies, which is often mistaken for dislocation of the hip joint, of which I have never seen a case. The part that is really broken is the neck of the ball of the head of the femur, which fits in the cup of the pelvis that goes to form the hip joint. In these cases great pain is caused by pulling the leg back or abducting it, and distinct crepitation may be felt and heard when moving the limb. ”

“ Sprains are common in a limb with weak muscles; in a deformed extremity in which the muscles act in unnatural lines, and in a joint with relaxed ligaments.
A joint, once sprained, is very liable to a repetition of the damage from slight force.
Symptoms. The symptoms manifested in a sprain are as follows: severe pain in the joint; nausea and sometimes syncope; impairment, or loss of motion; severe pain upon motion; early swelling if hemorrhage is severe—in any case swelling begins in a few hours; movement of the joint becomes [Pg 177] difficult or impossible ”

“ From the Knee it descends to the Foot, or mounts to the Hip, to the Loins, the Shoulder-blades, Elbow, Wrist, the Nape of the Neck, and frequently is felt in the intermediate Parts. Sometimes one Part is quite free from Pain, when another is attacked; at other Times many Parts are seized nearly at the same Instant; and I have sometimes seen every Joint afflicted at once. In this Case the Patient is in a very terrible Situation, being incapable of any Motion, and even dreading the Assistance of his Attendants, as he can scarcely admit of touching, without a sensible Aggravation of his Pains. ”

“ Pain that is definitely influenced by motion, as by the jarring effect of walking, or by bending and stooping, is practically always organic. The best differential diagnosis between neurotic abdominal conditions and organic trouble can be made by the help of information obtained in this way. If the appendix is inflamed, or the gall bladder infected, or contains a calculus, or if the kidney has a calculus, these are all made worse by movements, by jarring, by stooping as in tying the shoes, by riding on rough roads, and the like. ”

“ If, while in action, the animal is suddenly made to halt, the act is accompanied with much pain, the back suddenly arching or bending laterally, and perhaps the hind legs thrown under the body, as if unable to perform their functions in stopping, and sometimes it is only accomplished at the cost of a sudden and severe fall. ”

“ The movements of a dislocated joint are usually limited. If any movement of the end of one of the bones is felt, it is always at an abnormal point. Pain is referred to the dislocated joint and the patient is unable to use the limb.
Treatment. As a rule, a dislocation should be reduced as soon as the diagnosis is made, and, if necessary, an anesthetic should be administered.
When reduction has been accomplished, the bone often goes back with a snap, the contour of the limb is restored, and the movements of the joint are free again. ”

“ The location of pain is not always at the seat of the disease. In hip-disease, the pain is not first felt in the hip, but in the knee-joint. In chronic inflammation of the liver, the pain is generally most severe in the right shoulder and arm. Disease of the kidneys occasionally produces numbness of the thigh and drawing up of the testicle, and commonly causes colicky pains. Inflammation of the meninges of the brain is often indicated by nausea and vomiting before attention is directed to the head. ”

“ Sometimes the pain is confined to the knee, and if the examination is restricted to that joint the disease at the hip may be overlooked. At this stage the attitude of the limb is not constant; at one time it may be natural, and at another slightly flexed and abducted. Tenderness of the joint may be elicited by pressing either in front or behind the head of the bone, but is of little diagnostic importance. ”

“ You have a View of the whole Argument in a few familiar Examples: The Pain of Abstinence from Food, as it is greater or less, produces a greater or less Desire of Eating, the Accomplishment of this Desire produces a greater or less Pleasure proportionate to it. The Pain of Confinement causes the Desire of Liberty, which accomplish'd, yields a Pleasure equal to that Pain of Confinement. The Pain of Labour and Fatigue causes the Pleasure of Rest, equal to that Pain. The Pain of Absence from Friends, produces the Pleasure of Meeting in exact proportion. ”

“ The administration of an anaesthetic, by relaxing the muscles, greatly assists the operation of reduction. The length of time that a joint has to be kept quiet after it has been restored to its normal shape depends on its form, but, as a rule, early movement is advisable. But when by the formation of the bones a joint is weak, as at the outer end of the collar-bone, and at the elbow-end of the radius, prolonged rest for the joint is necessary or dislocation may recur. ”

“ Under judicious treatment the synovitis generally clears up, but it may linger on and cause the formation of adhesions which may temporarily stiffen the joint; or it may, especially in tuberculous, septic or pyæmic infections, involve the cartilages, ligaments and bones in such serious changes as to destroy the joint, and possibly call for resection or amputation.
The symptoms of synovitis include stiffness and tenderness in the joint. The patient notices that movements cause pain. Effusion of fluid takes place, and there is marked fullness in the neighbourhood. ”

“ Tenderness is elicited on making pressure over the joint, on pressing together the iliac bones, or on attempting to abduct the limb while the pelvis is fixed. The muscles of the buttock and thigh are wasted. As any attempt to bear weight on the affected limb causes pain, the patient walks with a limp, and to save the joint he assumes an attitude which is characteristic: he throws his weight on the sound limb, leans forward, using a stick for support, tilts the affected side of the pelvis downwards, and flexes the hip and knee-joints of the diseased limb. ”

“ Walk, walk, walk with bleeding feet and smarting joints; walk with aching back and trembling knees; walk, though the senses grow giddy with fatigue, though the eyes droop with sleep, though every nerve, demanding rest, sets in motion its tiny alarm of pain. Death is at the end of that devious, winding maze of paths, crossed and re-crossed and crossed again. ”