Rest and pain : A course of lectures on the influence of mechanical and physiological rest in the treatment of accidents and surgical diseases, and the diagnostic value of pain. Delivered at the Royal College of Surgeons of England in the years 1860, 1861, and 1862 / by John Hilton ; edited by W.H.A. Jacobson.

John Hilton

Date:: 1879

Credit: Rest and pain : A course of lectures on the influence of mechanical and physiological rest in the treatment of accidents and surgical diseases, and the diagnostic value of pain. Delivered at the Royal College of Surgeons of England in the years 1860, 1861, and 1862 / by John Hilton ; edited by W.H.A. Jacobson. Source: Wellcome Collection.

Provider: This material has been provided by UCL Library Services. The original may be consulted at UCL (University College London)

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$horse ao-ain, and rode several miles home. This gentleman occupied him- self as ilsuai during thirteen days, occasionally riding, sometimes walking, but more frequently driving about the country in the pursuit of his busi- ness and attending one of the county markets. He then became the patient of the sura-eon who requested me to see him. At the time I saw him he was sufferino-from some indications of paralysis dependent on injury at the base of the Tkull, or high up in the cervical region. This patient subsequently died and upon examining his skull it was found that he had been the sub- ject of a fracture of its base; yet he pursued his ordinary avocations tor thirteen days without the slightest evidence of any cerebral or brain lesion, complainino- only of headache and some febrile condition. Now this frac- ture traversed that portion of the skull where the cerebro-spinal fluid is in- terposed between the bones of the skull and the brain structure. _ This is a o-ood illustration, demonstrating that the brain is not actually in contact with the bones at that particular spot. And it shows us also that a man may have a fracture at the base of the skull without, at that time, mani- festing any evidence of serious lesion. Supposing a patient to receive a severe'blow at the back of the skull: which part of the brain is most likely to suffer local lesion ? Certainly not that part of the brain which lies immediately under the point which was struck; but experience points distinctly to the anterior inferior part of the brain as most prone to local injury. In the anatomical fact to which I just now alluded, we shall see the explanation of that circumstance. This is the part of the brain which rests accurately upon, and in complete surface coaptation with, the bones of the skull. When the blow is received at the posterior part of the skull, the whole mass of the brain being driven forwards from the momen- tum given to it by the blow upon the bones of the skull, the under sur- face of the anterior part of the brain rubs over the depressed and elevated surfaces which constitute the anatomical features of the anterior fossa of the internal base of the skull. I have seen a case where the blow which led to the fatal injury was received at the back of the skull; no injury was inflicted upon the subjacent part of the brain, the whole effect was propagated to its anterior part—that part which fits accurately upon the bones of the skull—here the under and anterior part of the brain was very much lacerated. These circumstances taken together will show, I think, the practical advantage of distinguishing the parts of the brain which fit accurately upon the skull from those parts which are separated from it by the interposition of the cerebro-spinal fluid. The cerebro-spinal fluid has a specific gravity of about 1007. It con- tains scarcely any albumen, and is, therefore, very different from the serum of the blood. The function of this cerebro-spinal fluid is chiefly mechanical—that is, first to protect the more important parts of the brain from vibratory communications from the bones of the skull which might otherwise reach them;* the brain, therefore, at its base does not rest upon the bones, but upon the fluid; secondly, this fluid isolates the various nerves passing near each other towards the same foramina; and, lastly, supported by the cerebral circulation, it tends to bring back the in- ternal organs of the brain to a state of comparative emptiness or quies- * Mr. Ililton has shovra elsewhere (Lectures on the Cranium) that many of the ridges on the inner surface of the base of the skull serve to condnct vibrations to the clinoid processes which lie surrounded by cerebro-spinal fluid, and that the vibrations arrested and lost in this fluid are thus prevented from damaging the base of the brain.—[Ed.]$

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