« ForrigeFortsæt »
REST IN CONSERVATIVE SURGERY.
By S. E. MARTIN, M. D., Topeka, Kansas.
Pain is the most important characteristic, pathologically, which the physician is required to consider. He must determine first of all the condition of which it is a feature, and afford relief as surely and promptly as lies within his power. Before going farther, therefore, let me ask in regard to that specific condition usually termed neuralgic, whether it is really an exaltation of the function of sensibility. It has certainly been described by many distinguished writers as an hyperæsthesia, or excess of function. Others, however, deny this. Then confusion is made from the difference between function and action. The former in the natural activity of the organ, whereas the latter includes all processes of acting or moving, whether normal or otherwise. The action of the nerves may be extended to perturbations far exceeding any ordinary functional motion. The disturbance of nerve-force which is manifested by tetanic convulsions will not be regarded as merely an exaggerated degree of the orderly action by which the nervous system responds to a volition and impels a given set of muscles to contract.
The functions of the sensory nerves in a state of health is to convey sensation to the perceptive focuses. For example, the large surface of nerve-terminals represented by the collective peripheal branches of the fifth pair of nerves receives an impression from atmospheric conditions, and transmits it to the medulla oblongata. When the air is neither hot or cold, the sensation thus imparted is agreeable, and results in the reflex action of breathing. When, however, the temperature is cold and chilly, reflex actions of an abnormal character are produced, as pain and sneezing. It is absurd, therefore, to consider sneezing a normal performance of the functions of those nerves the office of which is to regulate expirations. In like manner, it is absurd to declare pain to be the natural function of the sensory fibres of the trigeminus.
Sir William Hamilton, in his work, Theory of Relations of Perception and Common Sensation, remarks: "The best way
to illustrate looseness and incorrectness of applying the term hyperæsthesia (implying exalted function) to the state of sensative nerves when suffering pain, is to examine the condition of distinctive preception in the very same parts to which the painful nerves are distributed. It will invariably be found that in parts which are acutely painful a marked bluntness of the tactile preceptions can be detected tactile preceptions are uo doubt conveyed by a different set of fibres from those which convey the sense of pain." Yet it cannot be supposed that the same influences in functional activity can be different, any more than exactly opposite in the two cases.
If, then, pain is not the heightening of ordinary sensation, it is a perversion. The impressions which the healthy nerve conveys are correct; whereas, those of pain are vague, unreliable, often deceptive. We are frequently unable to obtain a correct idea in regard to the organ which it seems to affect. In certain neuralgic conditions, for example, its actual seat is wide apart from the apparent spot where it seems to be in force; and the actual cause, or the structure involved, may be overlooked. This is an affection of the excito-motory division of the nervous system, according to Marshall Hall's classification, which comprises the gray matter or ganglia of the spinal marrow, and the afferent and efferent nerve-fibres pertaining all which are concerned in reflex actions, or those by which impressions are transmitted to a nerve-centre and reflected so as to produce muscular contraction without sensation or effect of will.
The most excruciating forms of pain, it will be found, have their origin in impairment of nutrition. Organic tumors afford a forcible illustration, producing during their growth a continuous pressure upon the nerve-trunks and their branches. Those pains may also be adduced which are attendant upon tonic contraction of the muscles. We find examples in acute pleuritis and peritonitis. Whatever the cause of these most intense of all acute pains, the friction and constant action incident to breathing, exert an important part in promoting them. An inflamed muscle that cannot be placed in a position of rest, but is compelled to maintain its ordinary func
tional activity, will inevitably be the seat of extraordinary perturbation of nerve-function, a condition very different from mere exaltation of the normal nervous energy. Dr. Thomas Inman, the author of various scientific as well as profound literary publications, makes this deduction: "It seems therefore an inevitable conclusion that a dynamic perturbation. going on in the non-nervous tissue is continued along the nerves themselves; and that the severity of the pains perceived by the conscious centers is porportionate to the tumultuousness, the want of co-ordination, and the waste with which force is endured in cramped muscle or whatever structure it may be in which pain has its source."
It may be considered as established, therefore, that pain is not exalted irritability or hyperæsthesia, but a sensation from disturbance of the nervous function in consequence of a lowering of the normal condition, which occasions an obstruction of the nervous communication and supply of nervous fluid. When this is complete, paralysis comes. It now devolves upon us to make a practical application of these facts to our theory of Rest in Conservative Surgery.
In the economy of nature the nervous organism which gives the body its vital supply is carefully protected by surrounding structure from exposure to friction or external pressure. The phrenic nerves, upon the integrity of which our life depends, after passing through the breast, traverse the diaphragm and give off their branches on the concave under-side of that muscle where they are completely shielded from compression during respiration. On the upper surface of the diaphragm where there is a repeated contact with the base of the lungs, it is easy to perceive that the filaments of the nerve would be constantly liable to pressure, and the action of the diaphragm itself dangerously complicated. The weight of the stomach, spleen and liver also operates to remove those organs from too close contiguity with the lower surface.
The great precision with which every muscle is supplied by its particular nerves enables us when we find a contracted muscle, to determine at once the nervous trunk and origin which occasions it. Dr. Erasmus Wilson remarks in his
Anatomy that we find the teres minor lying in contact with the infra-spinalis yet not receiving a branch from the suprascapular nerve. The four muscles lying between the os hyoides and the lower jaw, usually considered as forming one group, are perceived, when taken in connection with their nerve-supply to be really distinct and separable. The mylohyoid and the anterior belly of the digastric receive their nerves from the mylo-hyoid branch of the third division of the fifth pair. This fact indicates unerringly the relation which exists between these muscles and the process of mastication. The genio-hyoideus and the genio-hyoglossus, in their turn, are supplied by the hypoglossal nerve, and of course are associated functionally with the movements of the tongue.
Several muscles receive two distinct nerves. The adductor magnus of the thigh receives filaments from the obdurator, and also from the great sciatic. This demonstrates a double association of function, that the abductor magnus operates both with the adductor muscles and with the muscles at the back of the thigh. I will give another example of the relation of nerve-structure to muscle and function. The omohyoideus has a branch from the hypoglossal nerve, and if we trace that branch upward it will be found to receive a branch from the pneumogastric; and the muscle also has filaments from the cervical plexus. Thus we may perceive a triple association of function; one in connection with the hypoglossal region of the movements of the tongue and aided by the os hyoides; another in concert with the pneumogastric nerve to assist in respiration, and the third, in association with the movements of the neck.
The nerve-supply to the body and to the individual muscles is maintained with great uniformity. Every muscle receives precisely its proportion of nervous fluid, and never deviates in function. The careful and studious practitioner is enabled to do his part skilfully, by means of his thorough knowledge of the relations which the nervous system sustain to the muscular, and in regard to growth, waste and repair. The familiar acquaintance with the anatomical conditions of diseased structure will aid both in diagnosis and the proper application of
rest as a therapeutic agency. Pain is a symptom of disorder; its relief is the first duty, and the ascertaining of its cause a matter essential to successful treatment. When it is severe at any point, the natural supposition is that there is an inflammation at the affected part. We all know, however, that pain may exist and be accompanied with redness and swelling, when there is no local inflammation. Heat and increase of temperature are the reliable indications of inflammatory action. It is easy to find out, by applying the hand to a swollen joint or tendon, whether there is inflammation and what is its true character.
The first surgical case to which I was ever called was characterised by heat, swelling and redness the entire length of the leg. The patient had been considered as having inflammatory rheumatism, and was suffering intensely. After having carefully manipulated the limb, I perceived a manifest increase of heat and tenderness over the knee, especially over the external condyle. The inflammatory action had seemed as great above and below as at those points; nevertheless, I ventured to give as my judgment, in the face of a household of friends assured to the contrary, that the trouble was not rheumatism, but abscess on the knee-joint. I would have been dismissed summarily, but the patient took my part. He even refused to sanction the calling of any one in counsel. He was determined, he said, to give the "young doctor" an opportunity to prove his opinion. The pain at the time was excruciating. I administered an anodyne and applied a poultice to the part, composed of a strong decoction of the roots of Baptisia, thickened with bran. I predicted a result that would sustain my diagnosis. The abscess burst upon the eighth day after and discharged properly. The knee healed rapidly.
Some time afterward, however, I was called again. There was a large puffy swelling covering the whole surface where the abscess had been; but there was no abnormal heat, redness or pain. I considered it as occasioned by an adventitious tissue, possibly composed of serous and synovial membrane, and gave my opinion that by means of proper bandaging and rest it would be absorbed. The friends, however, were posi