There have been few surgical classics. Mr. Hilton, of Guy’s Hospital, London, England, wrote one about a century ago on The Therapeutic Influence of Rest and the Diagnostic Value of Pain. He pictured the expulsion from the Garden of Eden, the first wound, and resulting dismay; and, “the original promptings of nature to man for the alleviation of his altered condition. Pain was made the prime agent. Under injury, pain suggested the necessity of, and, indeed, compelled him to seek for, rest.”
His thesis was that nature could heal the injuries caused by wounds or disease only when the affected part was allowed to rest. And by rest he did not necessarily mean lying in bed or sitting in a chair. He spoke of physiological rest. A piece of dirt lodges under the eyelid and soon there is a conjunctivitis. Nature cannot cure this as long as there is no rest for the tissues because of irritation. Remove the dirt and rest will soon effect a cure even without silver nitrate.
Compound fractures in recent years have been treated by good cleaning, and putting up the affected parts in plaster casts where they cannot be disturbed by dressings or movements. This does not mean that the patient cannot tire himself out by traveling about on crutches. The patient with appendicitis gets physiological rest when the sick organ is taken out. Even a male can appreciate that a woman who was pregnant has achieved physiological rest when her constant companion of nine months is safely in the nursery.
On the other hand sometimes physical rest is needed. A physician caring for a rheumatic fever case may feel that he is putting extra work on the heart by allowing the patient to move about. He may doubt that this is compensated for by the aid to circulation that muscular activity gives. The liver is the largest organ of the body with a multitude of chores to do. Extra activity on the patient’s part undoubtedly increases these chores. So Dr. Chester Jones, of the Massachusetts General Hospital, speaking to us a few years ago on liver diseases, stressed, next to diet, the importance of physical rest in treating these conditions. At about the same time Dr. Thorndike, of the same institution, depicted to us the dangers of staying quietly in bed. His patients were started walking within twenty-four hours of abdominal operations, women were up and about forty-eight hours after childbirth, and even people with heart trouble were let out of bed promptly.
How do we explain these apparently divergent views emanating from this shrine of Aesculapius? First we must remember the human propensity to swing upon a pendulum, and that in nearly all matters we go in cycles from one extreme to another. A short generation ago obstetrical patients spent several weeks of convalescence in bed, especially if they were well-to-do and could afford the care. The modern shortage of hospital beds and the general enthusiasm for acceleration programs have tended to demonstrate that this is not at all necessary. But analysis may show that the two methods are not so divergent in results when considered from Mr. Hilton’s point of view.
Mr. Hilton had a patient who broke his leg and when put to bed developed jaundice. So Mr. Hilton reasoned as follows, I believe the congested liver which leads to the jaundice results from the forced rest to which the liver is subjected by the recumbent position; the circulation through the organ up to the period of the accident having been aided by active respiration and ordinary exercise. The withdrawal of these leads to congestion of the liver and hence jaundice.” It may well be that when a patient is too inactive and the circulation slows down, actual physiological rest is thus lost.
We all believe in physiological rest. In each case we must decide whether complete bodily rest will give this. As Hippocrates said in his first aphorism, “Decision is difficult.”
Although we will all accept rest as beneficent – and possibly my arguments may have produced a grumbling acceptance of pain – nevertheless it is with diffidence that I now ask you to include inflammation in this blessed category of protective devices. The word is, of course, closely related to inflammable, and refers to what Celsus, a hundred years after Christ, called the first of the four cardinal signs of inflammation: calor, rubor, tumor, and dolor (heat, redness, swelling, and pain).
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