RECAP 
 
 * "1 he Significance and 
 
 HX641 27290 
 RC73 . F49 1914 The significance and 
 
 
 Effect of Pain 
 
 
 
 
 
 
 
 Ether Day Address 
 1914 
 
 ? 
 
 
JK73 
 
 ±j£? 
 
 iniljeCtipofJtogark 
 
 College of ^Pfjpsitriansi anb iimrgeong 
 Hibrarp 
 
/ 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/significanceeffeOOfinn 
 
The Significance and 
 :: Effect of Pain :: 
 
 BY 
 JOHN M. T. FINNEY, M. D. 
 
 Professor of Clinical Surgery 
 Johns Hopkins Hospital 
 
 Ether Day Address 
 1914 
 

 Griffith-Stillings Press 
 Boston, Mass. 
 
THE SIGNIFICANCE AND EFFECT 
 OF PAIN* 
 
 By John M. T. Finney, M.D., Baltimore 
 Professor of Clinical Surgery, Johns Hopkins Hospital 
 
 For the great honor of being invited to deliver the Ether 
 Day Address for the year 1914, I wish first to express my 
 sincere thanks and appreciation to the trustees and officers 
 of the Massachusetts General Hospital. Returning, as I do, 
 after the lapse of a quarter of a century, my mind is filled 
 with memories of the time so pleasantly and profitably spent 
 as a house pupil in the wards of this hospital, just twenty- 
 five years ago. As a member of the old West Side surgical 
 staff, it was my great privilege to serve under those master 
 surgeons, John Homans, Charles B. Porter, and Arthur T. 
 Cabot, and to have the opportunity to observe the work of 
 their equally illustrious colleagues on the East Side, H. H. A. 
 Beach, Maurice H. Richardson, and John Collins Warren. 
 I should be untrue to myself and ungrateful indeed if I 
 failed at this time and in this place to acknowledge the 
 debt that I owe to these distinguished men and their associ- 
 ates upon the staff of this hospital, for the stimulus received 
 from them toward high ideals in thought and work; for 
 kindly admonition and advice; for encouragement when 
 sorely needed; and best of all, for that unconscious aid and 
 instruction so freely imparted and received in that intimate 
 personal association which always characterizes the relation- 
 ship between the true teacher and his pupils. The Massa- 
 chusetts General Hospital, in the value of its scientific 
 achievements and in its long roll of illustrious names, has 
 contributed much to American medicine. From its earliest 
 beginnings it has always stood for the best things in medicine 
 and surgery, and in many respects has served as a model for 
 others to follow. But illustrious as is its past and glorious 
 as are the promises for its future, for me at least it can never 
 be quite the same as it was twenty-five years ago. For I 
 miss the presence of those, my teachers and friends, who by 
 
 * Address delivered at the Massachusetts General Hospital , on Sixty-eighth Anni- 
 versary of Ether Day, October 16, 1914. 
 
their strong personalities made this hospital what it was to 
 us who were fortunate enough to have been in any way 
 associated with them. Recurring visits to these venerable 
 halls from time to time have been saddened by the loss, one 
 after another, of these familiar faces, until now but one 
 remains, full of years and of honors richly deserved and 
 honestly won. Long may he live, and never grow older, to 
 enjoy the fruits of his abundant labors and the affectionate 
 regard of his friends and former pupils. 
 
 Upon this occasion when we are gathered together to 
 celebrate what Dr. Mitchell has so happily termed the 
 "Death of Pain," it is fitting that we should stop for a 
 moment to consider as best we can just what it would mean 
 if this designation were literally true. Would that it were! 
 But as a matter of fact the field of usefulness of ether, large 
 and important as it is, does not extend far beyond the 
 confines of the operating room. Here it has through its 
 beneficent influence largely robbed surgical operations of 
 their terrors both for the patient and the surgeon, for in 
 these days the performance of a major surgical operation 
 upon a conscious, suffering patient is almost inconceivable. 
 They were indeed giants in the surgical profession in those 
 pre-anesthetic days, men of iron nerve and indomitable will, 
 who could bring themselves to inflict such untold anguish 
 upon their fellow-men, even in the hope of ultimate relief. 
 And what of the patient? This is but a marked illustration 
 of the impelling power of pain, for it requires but a bad 
 enough pain for a long enough time to break down all bar- 
 riers and to cause the sufferer to submit willingly, yes, 
 eagerly, to anything at all, even death itself, that offers hope 
 of relief. 
 
 We have tried with but ill success to picture in our mind 
 a world that was literally free from pain. What a Paradise 
 it would be! Suppose that such a thing as the abolition of 
 pain were possible. This of necessity would almost mean 
 the abolition of disease, for it is quite impossible to think of 
 pain apart from disease or injury, the two have been for so 
 long a time so intimately associated in the human mind. For 
 what is the meaning of the term disease, dis-ease, but the 
 opposite of comfort, and what is that in its commonest form 
 
 4 
 
but pain? Rob ill health of the pain it causes and its chief 
 terror is gone. But try for a moment to form some sort of 
 a mental picture of the conditions that would exist under 
 such circumstances. Would the world be better off or not? 
 In other words, is the existence of pain of any distinct 
 benefit to the human race, or is it not? In what ways is it 
 harmful, how beneficial? Every one who has been obliged 
 from any cause to experience it, or who has witnessed its 
 effect upon others, can well appreciate what a boon to 
 humanity its abolition would be. To be relieved of the 
 mental anguish, the awful fear and dread of a recurrence of 
 an attack of pain through which one may have passed, 
 means almost as much as to be relieved of the pain itself. 
 Think what all this would mean to suffering humanity. It 
 cannot be estimated! 
 
 On the other hand, is there anything that would be lost 
 that is of real advantage? This suggests the thought that, 
 after all, pain may have its uses and a definite value both to 
 the patient and to the surgeon. What are they? What are 
 its effects, good as well as bad? We may hope, perhaps, by 
 observation and investigation to gain some insight into these 
 effects and learn something of its clinical significance. It is 
 to this phase of the subject that I wish particularly to direct 
 your attention. 
 
 These questions must, I am sure, have come with especial 
 emphasis to every thoughtful surgeon, accustomed as he is 
 from the nature of his work to the sight and sounds of pain; 
 called upon as he is to inflict pain that relief may follow, to 
 witness daily its effects and results, and to try to find out 
 and remove its causes. They must also have come, and 
 with even greater force, to one who has been called upon 
 himself to lie upon a bed of suffering, and has counted the 
 hours as they dragged wearily and endlessly through the 
 long night watches; or who, while keeping sleepless vigil 
 by the bedside of some loved one, has listened helplessly to 
 the stifled cries and groans, or, harder still, has witnessed 
 in the agonized countenance the mute evidences of intense 
 pain. He must many times have wondered at it all and asked 
 himself the question, "Why must it be so?" Why should 
 human beings be called upon to suffer as some of them are, 
 
 5 
 
the innocent along with the guilty? Because the fathers 
 have eaten sour grapes why should the children's teeth be 
 put on edge? 
 
 Ever since that evening in the Garden of Eden when the 
 curse of sorrow and pain was placed upon our first parents 
 these as yet unanswered queries have lingered in the minds 
 of their descendants, and I fancy that they will continue 
 to arise in the minds of succeeding generations, and will 
 fail of a satisfactory answer until the dawning of that blessed 
 day to which reference is made in the inscription carved 
 upon the monument erected to commemorate this happy 
 event, which stands in yonder Public Garden, "Neither 
 shall there be any more pain." 
 
 The mystery of pain! Has anything in the way of human 
 experience given rise to more wonder or speculation than 
 this? The passions, love and hate, have at times, perhaps, 
 stirred to greater action or deeper feeling. Religious zeal 
 has aroused and lifted the thoughts and emotions to higher 
 planes, patriotism and the martial spirit have ever spurred 
 to deeds of heroism and valor, but I doubt whether any 
 other human experience has been more universal or more 
 controlling than that of pain. The pursuit of pleasure in 
 some of its manifold forms has occupied the mind more 
 continuously, perhaps, but the avoidance of pain and the 
 institution of measures to relieve it have ever occupied a 
 not inconsiderable share of its attention, and will continue 
 to do so until the end of time. 
 
 Most of the important epochs of a lifetime are intimately 
 associated with pain or are greatly influenced by it. The 
 beginning of life and the end of it are occasions that are 
 rarely dissociated from pain. We speak of the pains of 
 labor in such a way that the two terms are almost synony- 
 mous, and one rarely thinks of the one without the sug- 
 gestion of the other. This is likewise true of the other 
 extreme of life, but not to the same extent. The "pangs 
 of death" is an expression used by the poets, but neverthe- 
 less an intimate association of ideas is thereby expressed 
 which, while more fanciful than real, perhaps, has its effect 
 upon the human mind. Few experiences, indeed, there are 
 that are really worth while that are not in some way or other 
 
 6 
 
intimately associated with or influenced by human suffering. 
 Pain is such a universal experience that it has been felt in a 
 greater or less degree by every one. Indeed psychologists 
 tell us that we never have a sensation or an idea which is 
 not felt with some degree of pleasure or pain, and so it is 
 that the study of it has excited interest in many minds and 
 in all ages. But its cause and the reason why remain a 
 mystery still. 
 
 What will implacable, beyond our ken, 
 
 Set this stern fiat for the tribes of men! 
 
 This none shall 'scape who share our human fates : 
 
 One stern democracy of anguish waits 
 
 By poor men's cots, — within the rich man's gates. 
 
 What purpose hath it? Nay, thy quest is vain: 
 
 Earth hath no answer: if the baffled brain 
 
 Cries, 'tis to warn, to punish — Ah, refrain! 
 
 When writhes the child beneath the surgeon's hand, 
 
 What soul shall hope that pain to understand? 
 
 Lo! Science falters o'er the hopeless task, 
 
 And Love and Faith in vain an answer ask, 
 
 When thrilling nerves demand what good is wrought, 
 
 Where torture clogs the very source of thought. 
 
 — Weir Mitchell. 
 
 It is a difficult task that we have set ourselves, the dis- 
 cussion of the significance and effect of pain. The subject 
 is a very broad one, too broad, indeed, to do full justice to in 
 the limited time at our disposal. It is many sided, and we 
 can do no more than indicate and briefly discuss some of 
 the phases that are of particular interest and real significance 
 to the surgeon. 
 
 The cause of pain is one thing, its significance another. 
 But in order the more fully to understand the one we must 
 know something about the other. Indeed, it is absolutely 
 essential to' be more or less familiar with the results of 
 recent investigations in order to be able to understand many 
 of the phenomena observed. As is usually the case in every 
 live subject, the observations and opinions of investigators 
 in this field do not entirely agree. Nevertheless, certain 
 fundamental facts have been established, a brief summary 
 of which will aid us to a better understanding of our subject. 
 
 In the preparation of this paper we have consulted many 
 
 7 
 
authors, — Hilton, Lennander, Mackenzie, Ross, Head, 
 Sherrington, Meltzer, Hertz, Schmidt, Howell, Behan, Crile, 
 Cannon, and others, and we wish here to make acknowl- 
 edgment of the free use made of their opinions and results. 
 
 The anatomy and physiology of the pain-conducting 
 apparatus has been carefully studied by many observers, 
 but as yet no very satisfactory results have been obtained. 
 They tell us that "Pain is probably the sense that is most 
 widely distributed in the body. It is present throughout 
 the skin, and under certain conditions may be aroused by 
 stimulation of sensory nerves in the various visceral organs, 
 indeed in all the membranes of the body." 
 
 Experimental studies upon the exposed brains of living 
 animals, as well as clinical observations upon conscious 
 patients in the course of surgical operations, giving rise to 
 extensive explorations into the tissues of the brain itself, 
 lead to the belief that it is insensible to pain. Cushing was 
 the first to show that the dura also was insensible to the 
 ordinary stimuli for pain. The adequate stimulus here seems 
 to be, as in the intestine, tension in some form. 
 
 "For cutaneous pain, at least, the evidence is very strongly 
 in favor of the view that there exists a special set of fibers 
 which have a specific energy for pain. It would appear that 
 the pain sense has a punctiform distribution in the skin. 
 Histological examination of these pain points indicates that 
 they have no special end organ, the stimulus taking effect 
 upon the free end of the nerve fibers" (Howell). Any of 
 the usual forms of artificial nerve stimuli may affect these 
 endings, and if of sufficient intensity can give rise to pain. 
 Until comparatively recently it has been taken for granted 
 that the sensory phenomena of disease could be explained 
 only on the assumption that the viscera were well supplied 
 with nerve fibers which could convey impulses leading to 
 the sensation of pain (Hertz). Although as early as 1753 
 Haller, as pointed out by Hertz, had failed to obtain any 
 evidence that the pleura, peritoneum, lungs, liver, spleen, 
 or kidneys of animals were sensitive to pain, the first real 
 doubt was cast upon prevailing belief when it was observed 
 that during the second stage of a colostomy the manipula- 
 tion and cutting of the walls of the colon in a patient per- 
 
 8 
 
fectly conscious were unattended by pain, indeed were 
 entirely without sensation. The subject then became the 
 basis of wide interest and investigation. The publications 
 of different observers, notably Hilton in his classical lectures 
 on "Rest and Pain," and the investigations of Ross, pub- 
 lished in 1858, stimulated interest and further work in the 
 study of the nature and methods of transmission of pain. 
 
 In his investigations of visceral diseases Ross divided 
 pain into two forms, splanchnic and somatic. His ideas 
 were very similar to those which had been previously ex- 
 pressed by Hilton and Lange. He thought that " the impulses 
 produced by irritation of the peripheral terminations of the 
 splanchnic nerves were conducted by the posterior roots to 
 the posterior horns of the spinal cord, where they diffuse to 
 the roots of the corresponding somatic nerves, and thus 
 cause an associated pain in the territory of distribution of 
 these nerves." This work of Ross opened up a large field 
 for investigation and stimulated the splendid work of Head 
 and Mackenzie, who still further corroborated the observa- 
 tions of Hilton and Ross, and on the weight of their authority 
 these ideas became generally accepted. Head's work dealing 
 with the areas of cutaneous hyperalgesia occurring in visceral 
 disease, by demonstrating that they are identical with the 
 areas which receive their sensory nerve fibers from the 
 spinal segments to which the afferent fibers from the diseased 
 viscera pass, proved conclusively the soundness of the earlier 
 deductions. Divergent views were held by Mackenzie and 
 Ross as a result of their experiments. The former had 
 observed that in visceral disease in addition to the tenderness 
 in the skin, as mapped out by Head, there was a similar 
 sensitiveness in the muscles and parietal subperitoneal tissue, 
 supplied by the corresponding spinal segments. He as a 
 result of his observations came to the conclusion that all 
 pain in abdominal disease originates in the peripheral 
 structures. Ross, on the other hand, adhered to the idea of 
 splanchnic or visceral and somatic or referred pain. Since 
 this time much additional work has been done and published 
 records of investigations by many observers have accumu- 
 lated. From this mass of work several facts stand out 
 prominently: (1) That any nerve ending may be sensitive 
 
to some one form of stimulation which has been called "the 
 adequate stimulus," but insensitive to all others. The 
 failure to take this fact into account explains a great many 
 of the discrepancies which have occurred in the reports of 
 the work of earlier observers. The adequate stimuli for 
 pain vary for different regions and structures of the body, — 
 for instance, those for visceral pain are not of the ordinary 
 tactile or thermal types to which the skin and mucous sur- 
 faces so promptly respond, but are tension in some form or 
 other. It must not be forgotten, however, that while these 
 other forms of stimuli may not be capable of exciting specific 
 receptors in the intestinal walls, nevertheless they are capable 
 of inducing motor reflex activities which in turn cause con- 
 traction, and those contractions which cause tension to 
 mount to the deep sensibility threshold result in pain. A 
 great deal of discussion has been given to the question as 
 to the channels through which intestinal pain is transmitted, 
 but that pain is actually felt in lesions of the intestinal canal 
 cannot be doubted. (2) That the threshold of pain, that 
 is, the point at which pain as a result of any form of stimu- 
 lation begins to be felt, may be raised or lowered, according 
 to certain established conditions. (3) That tension in some 
 form or other is the commonest, perhaps the sole cause of 
 visceral pain. Meltzer in the course of his investigations 
 attempted to explain all forms of colic as due to a disturbance 
 of what he called "The law of contrary innervation," which 
 is the name he gave to the well-known physiological law of 
 the intestine, namely, that contraction in one place is always 
 associated with relaxation just below. Interference with 
 this law due to organic disease, or to direct or reflex spasm, 
 giving rise to tension as a result of traction upon the parietal 
 attachments, or distention of the intestinal wall, produces 
 visceral pain in some of its protean manifestations. Hertz 
 and others insist that this is the sole cause of true visceral 
 pain. This pain, in turn, is referred to the peripheral struc- 
 tures in accordance with the views expressed above. 
 
 From my own clinical observations made in the course of 
 surgical operations upon conscious patients I am convinced 
 that Ross is right in his contention that there are two forms 
 of pain, splanchnic and somatic, and that in a number of 
 
 10 
 
conditions at least — such, for instance, as the common 
 forms of colic, — visceral pain alone is present. It is not 
 always easy, indeed not possible, to distinguish between 
 these two forms of pain, for they are not infrequently both 
 present at the same time. 
 
 As against the idea that pain can originate in the viscera 
 has been urged the fact of the patient's inability accurately 
 to localize it. The same is true, of course, of the skin, as it 
 is well known that cutaneous irritation of certain parts of 
 the trunk cannot be localized within wide limits. The argu- 
 ment is advanced that if the pain of gastric ulcer, for instance, 
 is produced in the ulcer itself, it should move when the 
 stomach moves, but, as a matter of fact, the pain remains 
 stationary. This phenomenon is explained by Hertz on the 
 ground of average localization, that is, the pain is referred 
 to the point on the surface of the skin under which the 
 stomach should normally lie. He would give this as the 
 reason why visceral pain is most accurately localized in those 
 viscera which move the least, as the gall bladder, duodenum, 
 and esophagus, and is least accurately localized in the more 
 mobile portions, that is, the large and small intestine. 
 
 Cutaneous pains are as a rule located more or less accu- 
 rately at the point stimulated, whereas in the case of pain 
 arising in the internal organs this is not the case. Here are 
 observed what have been designated clinically as "referred 
 pains." Head in his classical studies of this subject has 
 shown very conclusively that the different visceral organs 
 have a more or less definite relation to certain areas in the 
 skin. With painstaking accuracy he has marked these out 
 and determined their association with the different spinal 
 segments. The misreference of pain observed is ascribed 
 to a diffusion in the nerve centers. This diffusion Head 
 explains on the ground that in the case of a painful stimulus 
 applied to a part of low sensibility in close central connec- 
 tion with a part of much higher sensibility, the pain pro- 
 duced is felt in the latter rather than in the former, to which 
 the stimulus was actually applied. It is generally accepted 
 by physiologists that the afferent neurones from the viscera 
 have a common path of entry into the cord from the posterior 
 root. The theory of "referred pain," then, is that "sorae- 
 
 11 
 
where in this common path the excitement of the splanchnic 
 afferents is transmitted to the somatic afferents, and that 
 the cerebral center for these being stimulated, the mind 
 suffers an illusion and refers the source of the irritation out 
 to an area of skin" (Harris). 
 
 A knowledge of these few facts will aid materially in the 
 understanding of that large and interesting group of reflected 
 or referred pains with which every surgeon of experience 
 is familiar. It is often difficult enough to determine with 
 any degree of accuracy the cause and significance of a pain 
 in the part directly affected. Take, for instance, a pain 
 occurring in the upper right-hand quadrant of the abdomen. 
 A great many possibilities at once suggest themselves to 
 any one familiar with the pathological anatomy of this 
 region. When, however, the pain is referred to some part 
 of the body far distant from its point of origin and is accom- 
 panied by no appreciable symptoms suggestive of this fact, 
 the difficulties in the way of an accurate diagnosis are 
 multiplied many fold. 
 
 For example, some years ago I was called in consultation 
 to see a youth of seventeen who the day before, while return- 
 ing from a chestnutting expedition, and after having eaten 
 very freely of the raw nuts, was suddenly seized with a 
 severe pain in the lower right side of the abdomen. There 
 was no history of similar previous attacks. I found the 
 boy in bed, his right leg drawn up. He looked sick, com- 
 plained of pain referred to the lower part of the abdomen. 
 Temperature and pulse both elevated, nausea and vomiting. 
 Examination showed tenderness over the lower part of the 
 abdomen on both sides. No muscle spasm. Attempts to 
 straighten the leg increased his pain. Hip joint negative, 
 slight pain on urination. There had been no chill. There 
 was present a cough which bothered him greatly. Expec- 
 toration was considerable, whitish. Examination of chest 
 was negative, except for a few coarse rales. Diagnosis 
 uncertain, probably appendicitis. Immediate removal to 
 the hospital was advised and declined until the next day, 
 when the patient entered the Johns Hopkins Hospital and 
 was seen in consultation with several members of the staff. 
 By this time the sputum had become slightly blood tinged. 
 
 12 
 
His cough caused a good deal of pain, especially in the lower 
 right side of the abdomen. Examination of the chest showed 
 only evidence of slight bronchitis. Abdomen fairly soft and 
 permitted deep palpation everywhere, except low down over 
 the symphysis and on the right side just above Poupart's 
 ligament. Pressure here gave pain and a slight muscle 
 spasm was present. The right thigh still remained flexed 
 and could not be extended without pain. No tenderness to 
 be made out about the hip joint or surrounding structures. 
 Examination otherwise negative. Leucocytes 19,500, tem- 
 perature 104, pulse 120. It was then learned for the first 
 time that the patient had been exposed to typhoid fever, 
 which fact influenced our opinion somewhat toward a 
 possible typhoid, although the widal was negative. A central 
 pneumonia with diaphragmatic pleurisy could not be ex- 
 cluded. Abdominal symptoms referred to the region of the 
 psoas muscle were also not satisfactorily explained. Two 
 days later the patient was seen by Dr. Osier, who dictated 
 the following note: "Suspicious spots in right flank sug- 
 gesting rose spots, definite dicrotism of pulse, some piping 
 rales over right base, some impairment in left axilla; there 
 is an indefinite mass just above the symphysis pubis, 
 palpable and tender." Dr. Osier concurred in the diagnosis 
 of possible typhoid fever. No appreciable change was 
 observed in the patient's symptoms during the next two 
 days, when suddenly a swelling appeared in the upper part 
 of the thigh. Synchronous with the appearance of this 
 swelling the abdominal pain and tenderness markedly 
 improved. The diagnosis was then changed to acute epiphy- 
 sitis with osteomyelitis of the upper end of the femur. The 
 swelling was at once incised and a considerable quantity of 
 pus evacuated. The patient improved considerably after 
 this and was apparently on the road to recovery, when he 
 developed a right-sided pneumothorax, to which he quickly 
 succumbed. 
 
 The most striking symptom in this case had been from 
 the beginning intense pain in the lower part of the abdomen, 
 but accompanied by such slight local tenderness and muscle 
 spasm as to make us doubtful of the existence of any definite 
 inflammatory lesion in the abdomen, and for this reason 
 
 13 
 
operation had been declined. And yet it was impossible to 
 determine definitely as to the nature of his trouble until the 
 appearance of the swelling in the upper part of the thigh 
 rendered certain the diagnosis. 
 
 One could multiply instances of the confusing and mis- 
 leading effect of referred pain, the pain in the knee from 
 hip disease, in the ear from cancer of the tongue, in the 
 abdomen in Pott's disease, in the absent member after 
 amputation, in the shoulder in gall bladder disease, and in 
 the arms in angina pectoris, but it will suffice to direct 
 attention strongly to the fact that pain is not infrequently 
 referred to localities far removed from the seat of the causa- 
 tive lesion; and in cases where local signs do not correspond 
 with those usually observed in pain arising in that locality 
 a thorough search should be instituted for a possible ex- 
 planation existing elsewhere. In doing so it is well to bear 
 in mind Hilton's axiom, namely, that "Pain felt in any 
 part must be expressed by the nerves supplying the part." 
 
 There is a definite psychology of pain difficult to under- 
 stand, perhaps, but nevertheless well recognized by every 
 intelligent observer. Some one has said that pain is the 
 resultant of two factors, the lesion and the patient, and in 
 order to arrive at an intelligent appreciation of its true 
 significance both must be thoroughly understood. 
 
 The mental state of the sufferer varies greatly in different 
 individuals and at different times. Frequently he will 
 unintentionally deceive the physician by his inability 
 accurately to describe his sensations; especially is this true 
 of pain, which is purely subjective. Again he may do so 
 intentionally by false statements as to its character, location, 
 and intensity. In some, pain brings out the heroic, often to 
 a very unexpected degree. In others it develops the hitherto 
 unsuspected "yellow streak." It does not always follow that 
 because a patient bears what appears to be a great amount 
 of pain with remarkable fortitude, that that individual is 
 more deserving of credit or shows greater self-control than 
 the one who does not; for it is a well-established fact that 
 pain is not felt to the same degree by all individuals alike, 
 some are much more tolerant of it than others. Indeed cases 
 have been reported of individuals naturally analgesic who 
 
 14 
 
do not seem to suffer pain at all. The analgesia of hysteria 
 is also well known and usually easily recognized. 
 
 What may cause intense suffering in one will produce 
 little effect upon another. I was struck with this fact not 
 long since while reducing a Pott's fracture in the case 
 of a young man who was in other respects in excellent health. 
 I suggested giving him an anesthetic, but he requested that 
 I proceed with my manipulations without it. I did so, and 
 with considerable difficulty and the exercise of some neces- 
 sary force succeeded in satisfactorily reducing the fracture. 
 During the whole procedure he had sat up in bed and watched 
 what was being done with great interest and with little 
 evidence of suffering. After it was over he declared that, 
 while it had not been an altogether agreeable sensation, he 
 had suffered no pain of any consequence. On the other hand, 
 it is a not infrequent occurrence to hear a patient declare, 
 and with every evidence of truthfulness, that he or she was 
 suffering extreme agony, when there was no demonstrable 
 physical or pathological basis to lead one to believe that 
 such was the case. What is known as temperament plays 
 a great part in the ability of an individual to bear pain. 
 Just what this is it would be difficult to state in words. The 
 old idea of the knowledge of the constitution of the patient 
 supposed to be possessed by the family doctor has something 
 to commend it. 
 
 Being but a subjective symptom it is at times hard to 
 estimate the degree of pain, or indeed whether or not it is 
 present at all, as it is easy to feign. There are certain signs, 
 however, which denote intense suffering and which when 
 present are usually unmistakable, the pinched features, the 
 knotted brow, the rolling eyes with widely dilated pupils, 
 the ashen countenance, the cool and clammy skin, the 
 thready pulse, the increased blood pressure, the hands 
 alternately clenched and opened, grasping wildly at sur- 
 rounding objects or persons, or perhaps pressed firmly over 
 the painful area, add to this the cries and groans, the bodily 
 contortions and writhing so frequently seen in this con- 
 nection, and a picture is presented so definite and unmis- 
 takable that it cannot fail to be recognized. But it is not 
 always thus, — one sees now and then exhibitions of won- 
 
 15 
 
derful fortitude in the bearing of suffering, when not a groan 
 escapes the sufferer nor any evidence of the existence of 
 pain, save that indefinable expression of countenance so well 
 understood by the initiated. Is there or can there be any- 
 thing more sublime or more inspiring in its effect upon others 
 than such an exhibition of self-control? Pain may be so 
 intense as to notably depress the heart's action, even to 
 temporary arrest. If of great intensity it may be complete 
 and death may follow. 
 
 The fear of pain plays a large part in its psychology. So 
 terror stricken, indeed, may an individual at times become 
 as to seek self-destruction in order to avoid a repetition of 
 some dreadful experience. It also exercises a markedly 
 deterring effect in various ways upon conduct, thus pre- 
 venting, through fear of painful consequences, many foolish 
 actions. 
 
 The wearing effect of pain upon one's powers of inhibition 
 must have attracted the attention of every surgeon. So 
 often does one see the defenses, one after another, broken 
 down by continued and recurring pain, — the individual 
 whose fortitude in the beginning may have been surprising 
 may gradually, owing to this peculiar effect, become in the 
 course of time the whining, complaining creature, shrinking and 
 crying aloud at the slightest touch, a sore trial and an object 
 of pity alike to every one with whom he comes in contact. 
 
 Others may become embittered and hardened, their 
 dispositions soured, their whole mental attitude and their 
 outlook upon life in general changed and rendered thoroughly 
 pessimistic by suffering. 
 
 There is upon the other hand perhaps no burden which 
 humanity is called upon to bear, unless it may be grief, which 
 itself is looked upon as a form of mental pain, that may 
 have so refining and ennobling an influence, or may bring 
 out more forcibly the higher qualities of head and heart, or 
 develop nobler traits of character. How forcibly is this 
 fact now and then brought home to all of us as we have 
 looked into the face of some patient sufferer, purified and 
 rendered truly beautiful by the discipline of pain, and how 
 much it has increased our admiration and respect for human 
 kind. 
 
 16 
 
Owing to the inability of the sensory apparatus to transmit 
 two strong impressions at the same time, the stronger of the 
 two for the moment will monopolize the attention of the 
 individual. The newspapers nowadays are rilled with thrill- 
 ing accounts of valorous deeds performed upon the battle- 
 fields by brave soldiers who, themselves severely wounded, 
 in the enthusiasm of the moment and unmindful, indeed for 
 the time being unconscious of their own suffering, have 
 rescued some more seriously wounded comrade, and then 
 after this has been accomplished, for the first time conscious 
 of their own pain, have collapsed. 
 
 Not long since I was interested and not a little amused to 
 observe in the crowd of yelling, dancing students who 
 swarmed upon the field at the end of a closely contested 
 game of football, a patient of mine, a student in the victorious 
 college, who not long before had severely injured his knee 
 while playing in a practice game, and since which time on 
 account of severe pain had been able to go about only with 
 the aid of crutches. He was careering as madly as the 
 nimblest among them, one crutch had been discarded, the 
 other was waving frantically in the air over his head, — for 
 the moment, at least, in the exuberance of joy in the success 
 of his team he appeared utterly oblivious to pain. The next 
 day when I saw him it is needless to say he was paying the 
 penalty. 
 
 Certain sensations which are not ordinarily associated 
 with pain may, when of sufficient intensity or when long 
 enough continued, gradually merge into it, — for instance, 
 those of fullness and emptiness accompanying an over- 
 distended or an empty stomach. To one who has survived 
 the starvation treatment of typhoid fever as practised in this 
 hospital twenty-five years ago, the pangs of hunger are no 
 figment of the imagination, but a real pain that leaves a 
 lasting impression upon the mind of the sufferer. I speak 
 feelingly. So also with heat and cold, and with certain 
 forms of local stimulation, chemical and otherwise, of the 
 tissues of the body, at first perhaps grateful, even pleasurable, 
 later and almost unconsciously, as the intensity increases, 
 becoming painful. So too every one who has experienced a 
 severe pain or has had the opportunity to observe its effecXs 
 
 17 
 
upon others must have noticed with satisfaction after its 
 subsidence the sensation of well-being, amounting at times 
 and especially in individuals of certain temperaments almost 
 to exhilaration. This is peculiarly so in women after the 
 completion of a hard and painful labor. One can readily 
 appreciate and understand the philosophy of the little 
 darkey when he said he "sho' did like to git kicked on de 
 shins, cause dey felt so good after dey stopped hurtin'." 
 
 "Every pain has its distinct and pregnant signification if 
 we will but carefully search for it." This sentence, quoted 
 from that classical work by Hilton, entitled "Lectures on 
 Rest and Pain," expresses better than can I in any other 
 words the idea that I had in mind in choosing the subject for 
 this address. If this be true then it follows of necessity that 
 the surgeon when consulted by a patient for the relief of his 
 pain will not have performed his whole duty toward his 
 patient if he has not made use of every means in his power 
 to discover just what is the peculiar significance of this 
 particular pain. It does not necessarily follow that even by 
 careful searching this significance can always be found out, 
 but this fact does not relieve the surgeon of the obligation 
 to make a bona fide effort to discover it. This search in turn 
 may involve some very complex and far-reaching problems. 
 It presupposes upon the part of the surgeon the requisite 
 amount of knowledge and training, coupled with the ability, 
 the willingness, and the facilities necessary to carry out the 
 examination and investigation in order to obtain the neces- 
 sary data; then more important than all is the judgment 
 with which properly to interpret the findings. For in 
 diagnosis symptoms are of value only when we are able to 
 interpret them in terms of the particular disease under con- 
 sideration. This is especially true in the case of subjective 
 symptoms, where so much 5 reliance has to be placed upon the 
 word of the patient. 
 
 A study of pain by itself is of interest and value to the 
 physician from a diagnostic standpoint. But when taken in 
 connection with other symptoms its proper interpretation is 
 rendered far easier. In attempting, then, to determine the 
 significance of a certain pain it is advisable not to dissociate 
 it from its attendant clinical phenomena; thus a pain in the 
 
 18 
 
epigastric region of a youth, when accompanied by tender- 
 ness and rigidity of the right rectus muscle in its lower half, a 
 rise in pulse rate and temperature, and an increase in the 
 leucocyte count, would very strongly suggest an acute 
 appendicitis rather than any other acute abdominal affec- 
 tion. This statement would seem elemental and almost self- 
 evident. But the frequency with which one sees the mistake 
 made of failing to recognize this fact prompts the reference 
 to it. Says Maurice Richardson, "Alone, pain indicates 
 danger in general; in combination with other signs it indi- 
 cates danger in particular and guides the surgeon's hand to 
 its source." But it alone cannot always be relied upon in 
 estimating the nature and extent of the causative lesion. 
 Many authors have dealt with this particular aspect of our 
 subject. Mackenzie especially has drawn attention to the 
 valuable aid to diagnosis afforded by a careful study of pain 
 and the nervous phenomena which accompany it. In our 
 effort to elicit the more obscure symptoms that arise from 
 disordered functions of diseased viscera it has sometimes 
 happened that insufficient attention has been paid to the 
 commoner and more obvious symptoms. The laboratory 
 methods of clinical diagnosis, the so-called special tests, are 
 of the utmost importance, and any attempt to decry them 
 should be deprecated. Yet it cannot be denied that to the 
 general practitioner at least, who is the one who sees the 
 patient first and who largely determines the course of treat- 
 ment to be thereafter followed, the practical value of these 
 methods is small as compared to the information to be gained 
 by the recognition and proper understanding of the symptoms 
 arising from reflex stimulation of the nervous system. We 
 must not shut our eyes to the fact that it is only in a small 
 proportion of cases which the general practitioner sees that 
 the more intricate methods of examination are of use or are 
 available. In the great majority of cases the reflex symptoms 
 lie ready to hand, if only they are recognized, and it is on 
 these alone that he has often to rely for early diagnosis and 
 treatment. How important it is, then, that the commoner 
 symptoms, such as pain, should be carefully studied, so that 
 their message may be correctly interpreted, for it is upon the 
 recognition of the early stages of disease that so much 
 
 19 
 
depends. This fact needs to be especially emphasized at 
 the present time, when, owing to the ease and comparative 
 safety with which an abdominal exploration can be per- 
 formed, the tendency in some quarters is setting so strongly 
 toward recourse to this easier and shorter method rather 
 than to a careful and painstaking examination and analysis 
 of the symptoms presented. As a result many operators (I 
 use the word advisedly, all operators are not surgeons) have 
 no clear idea in their minds with regard to the nature and 
 origin of many easily recognized evidences of disease. Espe- 
 cially is this true of the so-called reflex phenomena of visceral 
 disease. Of these pain is, of course, the most constant and 
 most important factor. It is easy to satisfy the patient 
 by calling his pain a neuritis or a neuralgia. But before 
 doing so the conscientious physician will consider most care- 
 fully the possibility of the existence of some other cause, 
 perhaps of visceral disease, and will take immediate steps to 
 eliminate it as a possibility or to establish its presence as a 
 certainty. It is of the utmost importance that the true 
 significance of these common symptoms, of which pain is 
 the most constant, should be recognized. 
 
 Do not discard the old and well-recognized symptoms and 
 methods for the new exclusively, but a study of the common 
 and easily ascertained facts by newer methods will throw a 
 new light upon them and allow of advances that can be made 
 in no other way. At the same time it should not be forgotten 
 that clinical contributions to our knowledge in this direction 
 constitute research work just as truly when made in the 
 wards, by the bedside of the patient, as when performed 
 upon animals in the laboratory. 
 
 Pain as a diagnostic factor is of the utmost importance. 
 It has been estimated that ninety per cent of all diseases either 
 begin with it or are at some time or other in their course 
 accompanied by it. In some cases it forms the all-important 
 factor, in others it is only an incident. The character of the 
 pain may be of great assistance in determining its significance. 
 Certain terms are used by patients so constantly in describing 
 pain arising from certain structures or pathological con- 
 ditions that they have come to have a definite diagnostic 
 value. For instance, pain arising in inflammatory processes, 
 
 20 
 
particularly of bone, is described as " boring" or " throbbing" 
 or "jumping" in character. Nerve pains are consistently 
 described as burning, shooting, or stabbing, while I have been 
 struck with the frequency with which the terms "stinging" 
 or "sticking" have been used by patients to describe the 
 painful sensations experienced fairly early in cancer of the 
 breast. While these and other descriptive terms cannot be 
 said to be of any absolute value they certainly are suggestive. 
 
 The relation that pain may bear to certain events is of 
 great assistance at times in differentiating between various 
 conditions. Can anything be more characteristic than the 
 pain of gastric or duodenal ulcer coming on, as it frequently 
 does, at a definite interval after the ingestion of food? Or, 
 more striking still, the pain of an anal fissure beginning 
 shortly after defecation, increasing for several hours until 
 the acme of intensity is reached, then gradually decreasing 
 until it entirely disappears and leaves the patient in perfect 
 comfort until this experience is repeated after the next stool? 
 
 Pain seems to be affected by the time of day. It is notori- 
 ously worse at night. How often, for instance, does one meet 
 with a patient suffering from an inflammatory bone lesion 
 who gives the history of inability to sleep at night because 
 of the pain, boring in character, which begins in the latter 
 part of the afternoon and gradually increases in intensity 
 through the night until towards daylight, when it rather 
 suddenly decreases to such an extent that sleep becomes 
 possible. 
 
 Weather conditions undoubtedly have their effect upon 
 pain. Especially is this true in the changes from good to 
 bad, which not infrequently increase the pain to such an 
 extent as to enable the patient to predict their occurrence 
 with remarkable accuracy. This has been attributed to 
 changes in atmospheric pressure, which affect the nerve 
 mechanism in much the same way as changes in the blood 
 pressure. This is probably the reason why pain is more 
 noticeable at night, although the quiet and the absence of 
 other things to distract one's attention undoubtedly have 
 their effect. It may be that the senses are more acute and 
 so perceive slighter irritation than by day. The recumbent 
 posture, and in the case of certain organs, e. g., bladder or 
 
 21 
 
stomach, their being more full or more empty than by day 
 may make a difference. 
 
 Racial characteristics are of importance. Those of the 
 so-called phlegmatic type bear pain better than others. 
 
 Sex is a factor not to be disregarded. One observer as 
 the result of his investigations insists that the well-known 
 ability of women to endure pain is due to the fact that their 
 sensibility to painful stimuli of all sorts is appreciably less 
 than that of men. 
 
 An important fact to be borne in mind is that abdominal 
 pain is usually accompanied by spasm of the muscles over- 
 ling the painful area, — the viscero-muscular reflex of 
 Mackenzie. Especially is this true of the recti, which have 
 the power of segmental contraction over the area of in- 
 flammation, and thus may strongly simulate tumors and 
 swellings of various sorts. 
 
 A striking instance of the protective action of pain is 
 seen in the case of the various inflammations of the serous 
 surfaces. Here, as Crile points out, the infections which 
 are associated with pain are those in which the trouble may 
 be made more widespread by muscular activity, hence the 
 tendency toward localization of the inflammatory process 
 which is encouraged by the fixation of the parts due to the 
 muscular rigidity which always accompanies to a greater 
 or less degree inflammations of serous surfaces. 
 
 The absence of pain where it may be reasonably expected 
 to be present or its sudden cessation in the course of certain 
 diseases are frequently of the greatest diagnostic significance. 
 Take, for instance, a tumor of the breast that has been 
 discovered accidentally, without previous warning of its 
 presence in the nature of uncomfortable sensations, is much 
 more apt to be of a serious nature than one which has given 
 rise to pain and discomfort. I am conscious always of a 
 sense of relief when a woman who has presented herself with 
 a tumor of the breast tells me that she has suffered great 
 pain in it, as this usually means that it is benign. 
 
 On the other hand, the history of the sudden cessation of 
 pain in the course of an acute inflammation in the right side 
 of the abdomen, for instance, may be of the gravest import, 
 particular^ if not associated with a corresponding drop in 
 
 22 
 
the temperature, pulse rate, and leucocyte count. Under 
 these circumstances it is an unfailing index of gangrene or 
 rupture of the appendix, or of the sudden breaking down of 
 the protective barriers between an abscess and the general 
 peritoneal cavity, a catastrophy which, unfortunately, is 
 not infrequently misunderstood and unrecognized by the 
 uninitiated. 
 
 As pointed out by Mayo in one of the previous Ether Day 
 addresses, medicine owes a great debt to surgery. Recent 
 accumulated observations upon the operating table have 
 laid the foundation of a true pathology of the living, and 
 have enabled us to recognize that there is a definite anatomi- 
 cal cause for many well-recognized groups of symptoms which 
 had hitherto been regarded as functional in origin. Through 
 the medium of surgical operations now performed with great 
 frequency and safety, but which were formerly regarded as 
 quite out of the question, we have been taught the true 
 significance of many of the symptoms which hitherto have 
 been universally misunderstood. Especially is this true with 
 regard to the affections that have to do with the abdominal 
 viscera, for here abdominal operations have added enor- 
 mously to our knowledge of the significance of pain by 
 demonstrating both its immediate and its contributing 
 causes. 
 
 But although the significance of certain painful sensations 
 may be thus understood, their actual cause is in many 
 instances as obscure as ever. The difficulty lies in trying to 
 understand the origin of pathological sensations so long as 
 the degree of sensibility of healthy or diseased organs to 
 various stimuli remains largely unknown. 
 
 Pain is probably the most generally present as well as 
 the most trying of all symptoms, and therefore the most 
 important as an aid to diagnosis and as a monitor in directing 
 and fixing the attention of the patient to the fact that there 
 is something wrong. To this extent it is distinctly beneficial. 
 So it is, then, that pain is not always wholly harmful in its 
 effects upon the individual or the race, and, as such, is a 
 not unmixed evil, at times even a real blessing in disguise. 
 
 The especial value of pain to the patient lies in the fact 
 that in most pathological conditions, if it is not the first index 
 
 23 
 
of existing trouble, it is nevertheless the first whose warnings 
 are heeded. 
 
 Incidentally pain is a good friend to the doctor as well. 
 It, more than any other factor, brings him patients. For 
 while other and sometimes even more significant symptoms 
 may have existed unheeded for a long time, it is only a 
 matter of a bad enough pain when every one is driven to seek 
 relief at the hands of his doctor. Failing in this he now 
 willingly, yes, eagerly, seeks the formerly dreaded surgeon. 
 Indirectly pain may serve the patient a good turn through 
 the medium of his doctor, for it is unquestionably true that 
 the surgeon who has himself been operated upon as a result 
 thereof is apt to display a more intelligent and sympathetic 
 interest in his patient's comfort. In his hands unnecessarily 
 rough manipulation of sensitive structures and too tight 
 bandages are apt to be of infrequent occurrence. 
 
 In these latter days when, owing to the predominating 
 influence of certain individuals or schools of medicine, the 
 trend of medical teaching has set so strongly toward thera- 
 peutic nihilism, one is apt to forget that the duty of the 
 physician or surgeon does not end with the completion of 
 an exhaustive and scientifically accurate physical examina- 
 tion and diagnosis, but that it is just as much a part of it 
 to treat the ills, physical and mental, real or imaginary, of 
 his patient. Indeed it not infrequently happens that the 
 treatment of the case may require a far greater exercise of 
 knowledge and of judgment than the diagnosis, which in 
 many cases can be made in the laboratory without even 
 seeing the patient. It is not my purpose to belittle in any 
 way the value to the physician of diagnostic ability of the 
 highest order, — far from it, — but I do wish to emphasize 
 the necessity of paying greater attention to the complaints of 
 the patient, especially to his history of pain, failure to relieve 
 which, upon the part of the doctor, is so apt to be followed 
 by a resort to the charlatan and the quack. Recognition 
 of this fact, aided greatly by the untiring efforts of a member 
 of the medical staff of this hospital, Richard Cabot, is slowly 
 gaining headway. The profession — largely due, I am 
 constrained to believe, to a misconception of its duty in this 
 regard, to faulty teaching, and as a reaction against over- 
 
 24 
 
dosage and the blind administration of drugs — has neglected 
 its duty in this respect. I shall never forget an incident that 
 happened early in my professional career and which made a 
 lasting impression upon me. An elderly physician, a type 
 of the old school family physician, was ill with angina 
 pectoris, from which he suffered paroxysms of intense pain. 
 He was attended by the foremost physician of the city, a 
 leader in his profession, a professor of medicine in the local 
 school. Realizing the desperate and hopeless character of 
 his malady, little had been done for the patient save careful 
 nursing and rest in bed. I happened to be present upon the 
 occasion of one of the attending physician's characteristic 
 visits, a cheer}' greeting, a jolly, a glance at the chart, a 
 momentary examination of the chest, a whispered conversa- 
 tion with the nurse, a skillful interruption of attempted 
 statements or parrying of questions upon the part of the 
 patient, a short adieu, and a rather hurried exit, which in 
 this instance was delayed somewhat by a vehement outburst 
 upon the part of the patient of righteous indignation that 
 no apparent steps had been taken toward the relief of the 
 intense pain from which he was suffering. Turning to me 
 the patient exclaimed: " What's the use of having the best 
 doctor in the city if he does nothing but make a diagnosis 
 and give you a jolly? I am suffering agonizing pain and I 
 want some relief. I had rather have a fifth-rate doctor who 
 relieved my pain than the best doctor in the country who 
 does nothing but make a diagnosis." It is only fair to add 
 that this plea brought the desired relief in the shape of a 
 p.r.n. order for a hypodermic of morphia. 
 
 It must not be forgotten that the good effects of pain occur 
 early in the course of the disease. Later, and the longer it is 
 continued, the more injurious it becomes. This fact, should 
 materially modify its treatment. In the beginning and until 
 the diagnosis has been made, or at least until the possible 
 causes of the pain have been as far as possible determined, 
 the effect of the pain, by calling attention to the existence of 
 trouble and helping to locate it, is distinctly beneficial. 
 During this period anodynes and analgesics, except in 
 extreme cases, should be withheld. But as soon as the pain 
 has ceased longer to be of service, and by its continuance 
 
 25 
 
can only do harm by reducing the patient's resistance and 
 exhausting his nervous energy, then it is that relief, adequate 
 and complete, is urgently indicated. But just here is required 
 the exercise of that sine qua non for the proper carrying out 
 of all surgical procedures, namely, good judgment. It is 
 essential to the successful treatment of any case where pain 
 is a prominent feature to know when to withhold anodynes so 
 as not to mask the clinical picture, and when to administer 
 them. For upon the full recognition of this fact will not 
 infrequently rest success or failure. Just here a word of 
 warning and protest ought to be sounded against the practice 
 which is far too prevalent, namely, the indiscriminate use 
 of drugs of all sorts, either with or without the recommenda- 
 tion of a physician. My attention was directed to this only 
 recently, when I was called to see a girl of thirteen who had 
 been suffering greatly from recurrent attacks of headache, 
 and for which her mother told me she had upon her own 
 authority been giving the child for some time doses of 
 gr. xx of aspirin three times daily, the ill effects of which 
 were very apparent in her condition. Far too great risks 
 are thus incurred of establishing the drug habit in susceptible 
 individuals. 
 
 The desired results may usually be obtained by the 
 competent and conscientious surgeon, while at the same 
 time safeguarding the best interests of the patient. 
 
 The proper use of drugs directed toward the relief of pain 
 may be productive of great good in materially lessening its 
 ill effects, by robbing disease of its greatest terror, by render- 
 ing far less formidable surgical operations, and shortening 
 convalescence through the conservation of physical and 
 nervous energy. There are many agencies at our disposal 
 in addition to drugs to be used for this purpose. Hilton 
 early called attention to the great therapeutic value of 
 physiological rest. The X-rays and radium are useful in 
 relieving the pain of inoperable carcinoma. Crile with his 
 anoci-association has made a distinct addition to our 
 armamentarium. But among them all, and their name is 
 legion, ether is easily the first, and, all things considered, has 
 for general use no real rival. 
 
 Fortunately the beneficent effect of ether is most felt in 
 
 26 
 
that large group of cases in which pain accomplishes no 
 good purpose. The pain of a surgical operation can be of 
 no possible advantage either to the patient or the surgeon. 
 On the contrary, it greatly exhausts the nervous energy of 
 the patient, lowers his resisting powers, and so delays con- 
 valescence, while it interferes very materially with the 
 operations of the surgeon, not only physical, but mental. 
 For no human being — and I have found surgeons as a class 
 intensely human as well as humane — can do his best 
 knowing that he is inflicting untold suffering upon his 
 patient; and no patient, under the stimulus of such intense 
 physical pain, can remain sufficiently quiet to permit the 
 surgeon to do his work under satisfactory conditions. 
 
 While in its immediate or its after effects it may not be 
 an ideal anesthetic, nevertheless when properly administered, 
 as it should always be by expert hands, either alone or when 
 preceded by or in combination with other drugs, as practised 
 in certain clinics, the good effects of ether are so pronounced 
 and its ill effects so reduced to the minimum, while at the 
 same time the risks are so infinitesimal as to make it alto- 
 gether the greatest boon ever given to suffering humanity. 
 No wonder, then, that the trustees of the Massachusetts 
 General Hospital should have instituted the custom of 
 meeting annually to commemorate the first public use of 
 ether in the performance of a surgical operation in this 
 hospital sixty-eight years ago. All honor to the great names 
 of Morton and Warren, and to this noble institution, for their 
 respective parts in that epoch-making event. 
 
 27 
 
COLUMBIA UNIVERSITY LIBRARIES 
 
 This book is due on the date indicated below, or at the 
 expiration of a definite period after the date of borrowing, as 
 provided by the rules of the Library or by special arrange- 
 ment with the Librarian in charge. 
 
 DATE BORROWED 
 
 DATE DUE 
 
 DATE BORROWED 
 
 DATE DUE 
 
 
 
 
 
 
 
 !■ ?*% "b" s\ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C28(i14i)m100 
 
 
 
 
COLUMBIA UNIVERSITY LIBRARIES 
 
 0064223353