No. 1928.

AUGUST 11, 1860.

A Course of LecturesON

P A I N,AND THE

THERAPEUTIC INFLUENCE OF MECHANICALAND PHYSIOLOGICAL REST

IN

ACCIDENTS & SURGICAL DISEASES.

Delivered in the Theatre of the Royal College of Surgeons.

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

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

LECTURE I.—(PART II.)REPAIR is but the repetition of growth, and the same ele-

ments, the same kindred conditions, are necessary to the same.results. Rest is the necessary antecedent to the healthyaccomplishment of each (i. e., repair and growth); and this

surely is the natural suggestion of a means towards an endwhich should never be lost sight of by the physician or surgeon.For example, children who are ill and lose their rest waste

very rapidly, more rapidly in proportion than older people;but as soon as the morbid condition subsides, and rest assertsits power, the recovery or repair becomes extremely active,accompanied by an increased tendency to sleep-that sleepwhich seemed to be the great desideratum.Take, for example, the case of a child suffering much from

the irritation of stone in the bladder, which prevents sleep,induces extreme attenuation, and urges the child even to theverge of death. How marked, how almost immediate is the

change on the removal of the stone !-in other words, on givingrest to the bladder, and consequent constitutional rest to thegeneral system. The child falls into a profound and prolongedsleep.

In principle, the same remarks and the same reasons wouldapply to cases of extreme dyspnoea relieved by the operationof tracheotomy, or cases of strangulated hernia after the reduc-tion by taxis or knife, or to the removal of an extraneous bodyfrom the auditory canal. In these and in many other instances !,which might be adduced, the relief afforded by the surgeon isoften followed by long and highly restorative sleep in children.

The interruption of rest by local disease, occurring to a personin the middle period of life, does not cause the same degree ofexhaustion and wasting as in the younger. They bear the lossof sleep better, because their constitution has to sustain thestress of repair only-not of both development and repair, asin the child; their recovery is slower; their subsequent sleepis not so profound nor so prolonged, nor their rest so complete.The defective sleep and slow repair which manifest themselvesin the old after injury of any kind are familiar to us all.What I have here endeavoured to inculcate is, that growth

and repair bear an exact relation to due physiological rest,local and general.

Although it is, I believe, impossible to explain what are theprofoundly delicate elaborations which are appended to, andassociated with, repair and growth (those marvellous renewalsof life and strength resulting from repose and rest), I need notinsist upon their obviously beneficial and constant ministrationto the exigencies, emergencies, and necessities of man’s life on-earth. Although it is impossible to explain how those myriadsof agents, of inconceivable minuteness, carry on their reconditelabours, we nevertheless know that they are stimulated byforces whose exquisite balance is very readily disturbed: prac-tieally, the maximum of result is co-equal with the minimumof disturbance, and thus rest becomes the great fosterer ofrepair. It is equally impossible to deny the manifestation ofthis influence of rest, whether we search for it in the seat ofman’s highest intellectual faculties, or in the vital endowmentsof a simple tube forming a bloodvessel.Let me employ a familiar example to illustrate the effect of

rest to the brain, by referring to any overworked member of

our own profession at the end of the London season. Freefrom structural disease, but anxious, worn, looking much in-creased in years, exhausted by mental labour, not physicalexertion, he takes his holiday. His rest from professionalduties consists in riding, walking, fishing, shooting : it is

physical exertion and corporeal work which he selects for hisrelaxation; but during the same period he carefully excludesall mental worry. Now, I apprehend that under these circum-stances some parts of his brain are nearly at rest; others are

occupied with their appropriate function of superintending andregulating muscular exertion; he is, in fact, calling into activitythe latent or suspended function of the cerebral centres, leavingthe higher, the intellectual part of the brain, to work out itsown reoovery from over-fatigue or exhaustion by rest-that is,by freedom from its own peculiar function or occupation.After a time, he returns altogether changed in health and im-proved in general appearance, active, and full of mental vigour,and equal to the resumption of almost any amount of renewedprofessional exertion, without any fatigue to his brain.As a matter of observation, I might adduce this additional

remark in support of the intended deduction or conclusion re-garding the beneficial influence of rest, that those persons whodrop off to sleep quickly, anyhow or anywhere, and sleepsoundly, undisturbed by active dreaming, are, caeteris paribus,capable of sustaining a greater amount of mental and corpo-real exertion than those who find it difficult " to get off tosleep"-who sleep lightly, and dreaming much, awake butlittle refreshed. I suppose that the relative amount of com-

plete or incomplete rest to the brain is the explanation of thecapability of endurance of mental and physical exertion in theone case, and of the inability to accomplish an equal amountof what may be desired in the other.

Bearing on this subject, I, like others of our profession, havehad repeated occasions to observe gentlemen who work theirbrains and their nerves with an expenditure of energy incon-ceivable to the heedless or thoughtle?s multitude-men of wide-spread mercantile affairs-men occupied with important calcu-lations, engaged in money transactions on a large and anxiousscale-patients whose conditions attested the applicability ofthese remarks by their mental and physical exhaustion, bytheir depression of spirits, by their change of character inassuming an aspect of complete enervation and want of self-confidence. Yet, with such men, the restoration to health hasbeen made complete by mental leisure, by " going out of town," and taking plenty of exercise in the open ain but abstainingfrom their business, the real disturbing cause.

In order to give this subject some additional practical in-terest in reference to cases of more decided mental disturbancefrom overwork of the brain, I may be permitted to read thisnote from my friend, Dr. Hood, of Bethlehem Hospital :-

"March 22nd, 1860."My DEAR SIR,—In reply to your inquiries, I may state

that I am frequently applied to for the admission of lunaticsinto this hospital, whose insanity is caused by over mentalwork, anxiety, or exertion, and for whose cases nothing is re-quired to restore the mental equilibrium but rest. Therapeu-tical measures are not necessary; all the mind seems to need isentire repose. I do not by this mean to imply that the patientreduced to a state of nervous hypochondriasis, or the depressionof melancholia, is to lead an indolent life. Such a course wouldonly aggravate the disease, and probably result in complete de-mentia ; but that those faculties which have been overstretchedshould have an opportunity of regaining their elasticity by restand relaxation. For example, an accountant, whose whole dayis spent in calculation and thought, becomes by overwork somentally fatigued that he is incapable of working out withaccuracy the most simple sum in arithmetic. Sensible of his

incapacity, which perhaps may result in the loss of his situa-tion, and with poverty then staring him in the face, he becomesmelancholic, and medical advice is sought. His physical func-tions are healthy; no medicine is required or taken, but a holi-day from the counting-house, freedom from all thought andanxiety, the substitution of amusement for labour, restores hismind to a healthy state, and he returns to business as compe-tent as he ever was. I have now under my care a man, whofor some years past has been subject to occasional attacks ofmelancholia. He is occupied as a compositor, and, being botha clever and trustworthy man, is constantly employed. Heworks early and late for many consecutive hours, and for somemonths all goes on well; but the stretch on the mind ultimatelycauses a break-down, from which he cannot rally, unless heleaves his business for a month or six weeks, and takes a com- plete holiday. He tells me that the cause of his mental suffer-

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ing is from concentration of thought, and that rest removes the tain it so; thus allowing the individual minute secreting partsweight and agony of melancholia. In a word, he takes a of the liver to recover their physiological strength and theirmonth’s holiday, engages in no occupation requiring thought tone.or bringing with it anxiety, and returns to his duties with the Again, the liver is so placed as to have the additional ad van-mind of a young man. Some people may reply, ’this is not tage of pressure from without, by its subjection to the contrac-rest ; it is only a change of employment.’ I maintain it is per- tile power of the muscular walls of the abdominal parietes andfeet rest to the faculty which has been overworked. Of course the diaphragm, especially during exercise and hurried respira-we do not propose that the whole mind should remain fallow, tion ; and no doubt this explains the benefit of active walkingbut that the pressure should be removed from the particular ! exercise, in cases of congested or torpid liver, at which timepart which is fatigued. the liver is compressed between the diaphragm and the respi-"I could give you many illustrations from the wards of this ratory part or upper half of the abdominal parietes. I would

hospital, where we are called upon to treat mental symptoms ! here ask you to observe the effect ofjorced rest, or the absencein the cases of governesses, students, clerks, and clergymen; of this pressure upon the liver, in cases of accident necessitatingand rest is all they require, and with that the most aggravated the recumbent position, inducing congestion of the liver andcases are restored." jaundice, and possibly inflammation of the organ. For ex-

ample : we see a patient in good health suddenly placed upon’

Having thus very briefly and very imperfectly reviewed the his back by a fracture of the leg, the local injury being con-subject of rest in relation to the body generally, let us inquire fined most exactly to the leg. The fracture goes on well, butinto some of the expedients which Nature adopts to the same the patient in a few days is jaundiced, without much constitu-end in its individual organs. tional disturbance. A moderate diet and a few doses of blue-

Activity and rest, alternating and in due relation to each pill with saline purgatives soon dispose of the jaundice, andother, form the physiological basis of, and key to, health in thenceforward everything proceeds healthily. I believe theman, and, perhaps, in all living organs. All viscera (as in the congested liver, which leads to the jaundice, results from thecase of the brain, to which I have already alluded) require forced rest to which the liver is subjected by the recumbentthe alternate condition of activity and rest to keep them vigor- position; the circulation through the organ up to the period ofous and in health; and if this condition be not observed or at- the accident having been aided by active respiration and ordi-tended to, structural changes and deterioration of vital endow- nary exercise. The withdrawal of these aids leads to conges-ment or function are sure to happen to them. Indeed, in tion of the liver, and thence to jaundice. In other cases thereference to the etiology of the diseases of individual organs, it congested liver may terminate in inflammatory softening andmay be asserted that a large proportion of these diseases ori- abscess. The same kind of congestion of the lungs at theirginate in circumstances which deprive the organ of that rest bases and posterior obtuse margins may, and frequently does,which nature has rendered necessary to the performance of its take place under the influence of difficult and inefficient inspi-healthy function. ration, dependent upon the difficulty of moving the posterior

For example, the heart, overtasked by constant emotional parietes of the chest while the patient is in the horizontal pos-influences, or excessive athletic exercises, and thus deprived of ture. The circulation through those parts of the lungs is notits appropriate rest, becomes prone to the various alterations completed; and as the quantity of blood circulating, up to thein its structures, which necroscopic examinations daily reveal. period of the accident, was adapted to a free and complete re-The liver, unduly stimulated by excessive potations, an un- spiration, this want of balance between the area of the respira-necessary amount of food, or habitual irregularity of diet, (its tion and the quantity of blood circulating causes pulmonaryphysiological harmony with the other organs of digestion being congestion and pneumonia. We see this fact exemplified whenthus constantly disturbed.) glides into disorganization for the the patient is compelled to lie on one side, which, by inter--same reason. The kidney, too, if its function be disturbed fering with the mobility of the thoracic parietes of that side,by the abuse or too frequent use of alcoholic and other causes congestive pneumonia on that side only. I have repeat-fermented drinks, which entails an unnatural and continued edlv observed this one-sided pneumonia at the post-mortemstress either upon its Malpighian or tubular portions, obeys table associated with lateral posture of the patient during life.the same tendency to structural deterioration, as a consequence The duty of the surgeon is to reduce the quantity of the circu-of its loss of due rest. lating fluid by purgatives and diaphoretics, and to allow theHow different is the effect of rest upon any machinery in- patient to sit, if practicable, so that the chest may be as little

vented or constructed by man; how utterly abandoned is the as possible encumbered by position. No doubt it was the fatalexpectation or hope of man’s ever contriving any machinery effects upon the lungs and liver, which local and remote acci-that may have the power to repair its own waste of structure, dents seemed to produce, which induced our forefathers to " letor to renovate, by its own inherent capability, any defect in blood" in almost every kind of accident which compelled the-its combination. However exquisite and perfect it may appear patient to keep quiet, or in bed.to be, its " wear and tear" is continuous with its mechanical The spleen has a strong elastic capsule, and also an internalactivity; its rest creates its own impeifections, and induces network of highly elastic tissue, so that the interior of thedecay; its necessary renewal is the substitution, by other hands, organ may, when necessary, be compressed, and its gorgedof a new and like material. condition reduced to comparative emptiness.

It is, I believe, an admitted physiological axiom, that each The kidneys also possess a strong elastic capsule, for thestructure or organ, whilst actively employed, is in a state of same purpose, and are also subjected to pressure by the weightvascular excitement or turgescence, and therefore enlarged of the superimposed colon.during that time. The tunica albuginea, which surrounds the testicle, tends in

So it is noticeable, that each organ of the body, which is like manner to empty the organ, and to give it rest.liable to the rapid supervention of activity in its proper func- The lungs are extremely elastic; this elastic property aiding,tion, is so placed in relation to surrounding structures as to without muscular force, the return of the lung to a state of rest-permit of temporary enlargement during the persistence of its or quietude after full inspirations which fill the lungs with air.exalted function; and that when it returns to its state of rest, I may here remark, that it is proved by the preparations beforeor period of self reparation, it may be said to have resumed its me, that the lungs have a very definite form, which adaptsnormal or standard dimensions. them, in their extremest healthy distension, to the surrounding

Secreting organs, in which vascular turgescence is extreme structures, without encroaching upon any of them. So we findand enduring, are relieved of their excessive congestion by their the lung specially grooved or hollowed out, to allow the cava3,tubular outlets, the elasticity of the enclosing capsule exerting descending aorta, arteria innominata, and left subclavian arteryits beneficial effect towards the same end by inducing centri- to pursue their courses without hindrance. I would ask thepetal pressure; this tends to diminish the size of the organ physician to ascertain what modification of form results fromas soon as its higher endowment, its engendered function of emphysema of the lungs, and what is the effect of this alteredphysiological excitement or orgasm, begins to diminish ; the form upon the heart, &c.* elastic capsule thus maintaining the healthy quiescent size of * The following is the plan I adopted successfully, more than twenty yearsthe organ. ago, for the purpose of injecting the human lungs so as to display the exactThe liver is enclosed within a strong elastic peritoneum, and configuration of their surfaces:-

.

it has also its proper elastic but thin capsule ; and I may add, tion of their the lungs and trachea carefully from the body without any lacera-it has also its proper elastic but thin capsule; and I may add, tion of their structures; suspend the lungs in a pail or small tub (large enoughas probable, that the structure found in Glisson’s capsule, sur- to allow of their full expansion), containing water sufficiently hot to maintainrounding the portal vessels, &c., in their distribution within melted tallow in a fluid state; introduce a large tube into the trachea, andthe liver, may influence their condition by its elasticity. These pour warm fluid tallow slowly through the tube until the lungs appear full;, then leave them for a short time submerged in the water, hot enough to keepforces, aided by the contractile power of the bloodvessels them- the tallow within the lungs in a state of fluidity. The air in the cells of the lungsRp.lves- bring the liver back to its condition of rest- and main- will gradually rise and find its wav out through the tube in the trachea, thus

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One of the largest and the most remarkable excavationsnoticeable on the right lung is found at the base of the middlelobe. This excavation corresponds with, or receives, the rightside of the right auricle of the heart; so that the right auricle,when distended with blood, as it frequently is, would, butfor this, be pressed upon by the base of the wedge-shaped massof lung, which is termed the third lobe. Another advantageof this arrangement is, that the right auricle, thus distended,exerts its mechanical influence upon a small portion of lung,which yields, and permits its distension. It is probable thatthis fact constitutes one of the reasons for the existence of athird lobe in the right lung; and it is worthy of this additionalremark, that this third lobe is wedge-shaped (a mechanical formseldom employed in the construction of the human body), andthat this wedge-force is the most powerful mechanical forcewhich can be employed; and being interposed between theupper and lower lobe is competent to separate them from eachother, and from the middle mediastinum containing the heart,&0. The preparation which I now present to you, demon-strates the anatomical relation of the right auricle and the baseof the middle lobe of the right lung which I have just de-scribed.

Quitting this digression regarding the surface anatomy of thelungs, I would observe, that if the views which I have ad.vanced in relation to Nature’s expedients to procure mechanicalrest be true in their anatomy and sound in their physiology, asapplied to the thoracic and abdominal viscera, they must be alsotrue of the brain; and this suggests the intention of the inter-stices between the convolutions and other sinuosities and spaceson the surface of the cerebrum, and opens up the probablereason for the existence and position of the ventricles of thebrain.One of the purposes of the lateral ventricles is to allow room for

the accumulation of venous blood in the plexus choroides duringa state of general cerebral congestion, as in sustained inspira-tion,-the cerebro-spinal fluid within the ventricle supportingthe bloodvessels, and so preventing their rupture. Mr. Queketttells me that any attempt to inject the plexus choroides, exceptin a fluid medium, is sure to cause rupture of the bloodvessels.

In order to point out the parallelism, in this respect, betweenthe mechanical appliances made use of in the cerebral circulation,and the like influence in these capsular organs within the chestand abdomen, let us consider the relation of some of the deep,enclosed, and internal parts of the collection or aggregation oforgans forming the brain.For instance, the corpus striatum and thalamus opticus are

placed within the cerebrum, and project into the lateral ven-tricles ; these parts, with the island of Reil, which occupies thespace between the anterior and middle lobes of the cerebrum,superintend the movement and sensibility of the upper andlower extremities.The completed brain, being enclosed within a solid case with

unyielding walls, admits of no possibility of eccentric enlarge-ment ; and if p’1,rts or organs liable to excessive or enduringfunction were placed within and surrounded by solid brain,they could not enlarge, except by pressure or encroachmentupon some other parts, without creating mischief; they couldnot, in fact, be obedient to the general principle in physiologywhich I have mentioned.

This increase of dimensions of the parts forming the floor ofthe lateral ventricles, however, is permitted towards the inte-rior of the ventricles, by the cerebro-spinal fluid recedingthrough the foramina, of Monro, third ventricle, aqueduct ofSylvius, fourth ventricle, and thence through the cerebro-spinalopening in the lower part of the fourth ventricle to the base ofthe brain or subcerebral spaces, and so into the vertebral canal.And as the local hyperaemia of the blood vessels in the interiorof the organs, thalamus, corpus striatum, &c., subsides, thecerebro-spinal fluid rises into the ventricles, and makes properlyadapted pressure upon the corpus striatum and thalamus, re-ducing them to their size of inactivity, and sustaining them ina state of rest. Properly adapted pressure is the pressure ofthe circulation, minus the local effect of physiological excita-tion in the part actively employed; the cerebro-spinal fluid inthis respect serving the analogous purpose of the elastic capsuleof the liver, kidney, and spleen.These sketches, copied from drawings made from nature, are

introduced for the purpose of showing the position of themaking space for the introduction of more melted tallow. This method ojproceeding must be repeated at intervals in the same slow and gentle manne!until the whole interior of the lungs and trachea is filled with fluid tallowThe lungs are then to be immeised in tepid, and subsequently in cold, wateruntil the tallow becomes quite firm. PreparatbnS made in this manner carbe preserved during many years.

cerebro-spinal opening in the human brain through which thecerebro-spinal fluid passes to and from the interior of the brain.The size and outline of the cerebro-spinal opening varies indifferent brains.

a Posterior and inferior part of the cerebellum overlyingthe medulla oblongata.

b Upper and posterior part of the medulla oblongata.c Cerebro-spinal opening for the transmission of the

cerebro-spiual fluid.

ON A CASE OF ABSCESS OF BONE.

OPERATION; CURE.

WITH CLINICAL LECTURE THEREON BY MR. QUAIN.

(Reported by W. L. WINTERBOTHAM,House-Surgeon to University College Hospital.)

CHARLES J-, aged thirty-one, married; a pale, fair-haired man; admitted May 3rd, 1859, into University CollegeHospital, under Mr. Quain.

Previous hi8tory.-Native of London; painter by trade, butnever had colic or rheumatism. When twelve years of age, he

severely twisted his right leg, and bruised the skin over thetibia. He was confined to bed five weeks, and a number ofopenings made their appearance over the front of the bone,through which matter and pieces of bone were discharged.When sixteen years and a half old, he struck his right knee,which caused it to swell, and occasioned much pain in thetibia; this was poulticed. An abscess then formed over the

upper end of the bone, which discharged and healed up. Two

years and a half ago, he slipped and struck the head of theright tibia against the rim of a barrel. He then entered this

hospital, -where the part was poulticed, and he left well in afortnight. The limb now remained sound till four weeks ago,when he again began to feel pain in it,-the pain being severestat night, and preventing him from sleeping. On this accounthe again applied for relief at the hospital.

Present state (May 5th).—When both legs are examined,there is a marked difference perceptible between them,-con-

fined, however, to the upper halves of the tibia. The rightone is considerably larger than the left, and is arched forwards,

. so that the part belov the head, usually slightly concave at, each side, is changed into a convexity. There is no redness or- other ulcerated appearance of the skin. When this part is. pressed on, the patient complains of an aching pain. This

pain, moreover, is always present in a slight degree; and, uponcarefi-il questioning, he states that there is a throbbing sensa-. tion, like, as he S3.ys, to the feel of a "gathered finger." Hel does not sleep ; his face expresses suffering; appetite bad; has, had distinct and repeated attacks of shivering, but none lately;

he suffers no pain except, in the diseased limb.Operation (May 10th).-Mr. Quain made a crucial incision

3 over the anterior surface of the right tibia, about two inches3 below the head, and applied a full-sized trephine. On remov-ing the bone, a large quantity of pus welled up from a cavityr in the cancellated tissue, of the size of a large walnut, at the

distance of about an inch and a half from the surface; into thisa strip of lint was inserted, and afterwards a poultice was

applied. Ordered to take a full dose of opium.