J. Mortimer-Granville
1879 The Lancet  
458 ankle in a layer of fine cotton-wool, applied a piece of moistened pasteboard to the sole of the foot, extending from a little beyond the heel to half an inch in front of the great toe, broad enough to embrace the tread of the foot. Across the ankle I placed two diagonal strips of moistened pasteboard, and fixed the whole with smoothly, but steadily, compressing bandage. The dressing was completed by fixing with a few turns of bandage a dry pasteboard splint to the sole of the foot, and
more » ... f the foot, and securing the lower part of the limb in the hollow of a pillow, tied round it with a couple of pieces of bandage. The patient was immediately comfortable, and continued so. He passed a good night, and when I saw him next day was quite easy. On removing the dressing after twenty-four hours, the toe was comparatively pale and shrunken, and could be handled comfortably. I reapplied the same dressing, but with firmer pressure. Forty-eight hours later improvement continued without interruption. I found the toe still further reduced, and as the sore, though cleaner, was not yet quite clean, I brushed over it, and into the crevices at its root and sides, with a fine camel-hair pencil dipped in the following lotioii -. -Borax, half a drachm ; compound tincture of lavender, a drachm and a half; glycerine an ounce and a half; water, six ounces. This appiication did not cause the least pain; a,nd when I had once more immobilised and compressed the foot, I was able to drop it from the height of a couple of feet on to the couch without the least discomfort. Valuable as dry dressing is in all recent wounds, lotions, similar to the foregoing in composition, are of essential service, when rightly employed, in foul wounds and old ulcers. The term "detergent" of the old surgeons has lost none of its fitness, and the therapeutic agents which it designates have lost none of their practical usefulness. In the case (5) now under consideration the result was largely due to absolute rest. The value of rest no one questions ; but what is needed is a more clear and precise understanding of the means to be adopted to carry it into effect. Rest, to be of real service in the multitude of surgical cases which are benefited by it, must be, as nearly as practicable, absolute; and the construction of immovable apparatus, suitable to the exigencies of particular cases, will be found to tax the ingenuity, and to demand the nicest combination of gentleness and strength. Pressure was another great factor in my patient's improvement. It was so partly, no doubt, as an aid to immobilisation, in unifying the parts of the apparatus and fixing the ankle and the smaller joints of the foot. But it must always be borne in mind that, whereas comparatively slight pressure, if hard and circumscribed, is painful ; uniform, smooth, elasti" pesssure, accurately applied, is most soothing. It acts by controlling the local circulation, preventing extravasation, promoting absorption of interstitial deposits, and lulling, to impotence for mischief, muscular spasm—that most potent cause of local and constitutional unrest. A wrist-joint, hot and swollen after a heavy fall on the hand ; an ankle after a slip and a twist, grown big and mottled and tender as a boil; a woman's pendulous, hot, tender breast, breeding an abscess; the fleshy, jumping stump of an amputated thigh, are one and all relieved, as if by magic, under steady, uniform, elasticpressure. That pressure of which the surgeons of the I)re-Hunteriaii epoch had so clear a conception, of which old Baynton of Bristol wrote so quaintly, John Bell and John Scott so eloquently yet so tersely, is all but forgotten. Little better has been the fate of the teaching of those modem classics, the elder Larrey and Seutin. Few understand the principle of, fewer still practise, pressure as inferior to none of the cardinal therapeutic surgical agencies. Rest and position, not as physiological abstractions, but as therapeutic agencies, carried out with all the resources and precision of surgical mechanics, are invaluable therapeutic resources, but it is only when combined with pressure that they enable the surgeon to realise the full power of vital endowment, to repair lesions and to resist the decaying tendencies inherent in dead organic matter. Conceding the antagonism of putrefactive changes and vital processes, and the value of agents which prevent or neutralise the products of decomposition, it is narrowing the basis of surgical science, to the exclusion of some of its greatest resources, to concentrate the attention on antiseptic indications. On broad scientific grounds, Mr. Savory's protest against the expression "antiseptic surgery " claims absent. In the vast majority of wounds coaptation, once affected and steadily maintained, is followed by union. In huch cases as a compound fracture, an amputation at the hip-joint, or ligature of an arterial trunk, frequent change of dressings to counteract germ infection is opposed to that great principle of REST, which, for local and constitutional reasons, is of the very essence of success. To assume as a general proposition, for revolutionising surgical practice, that infection exists ready made in the atmosphere, which only requires to be filtered of its germs as a condition precedent to the healing action, is to beg the whole question at issue, in the face of overwhelming clinical evidence to the contrary. Birmingham. THE fact that there is a practical difference between knowing a thing and being able to remember it is sure to be brought home to the student in any branch of science, very early in his career. What precisely is the nature of this difference, and how is it to be adjusted? Before we try to find answers to these homely but earnest questions, let us expose and put out of the way a source of misconception which often occasions trouble and disappointment to minds admirably fitted for intellectual work, but inexperienced in the exercise of their powers and faculties. A man of acute and clear perception, endowed with a quick understanding, will comprehend a subject, take it in with a rapid mental glance, and seem to have made it his own. He "learns ea,sily," but, alas, lie forgets with even greater facility. The truth is that he has never learnt in any mnemonic sense. What he has done is to apprehend; and although the brain is undoubtedly capable of a process analogous to instan. taneous photographing, it rarely performs this function at the behest of the will, unless it has been specially trained to do so ; or when it does thus instantly receive an impression, the record is not permanent. The faculty of instantaneous mental photography is more commonly the agent of the subconsciousness than of the supreme consciousness, and it takes in the impressions we would gladly have effaced, while those it is desired to retain are obliterated almost as soon as they are registered. Apprehension is a function of the intellect which may be, and in the case of what are called "clever" persons often is, developed to a high degree of efficiency without any corresponding exercise of the recording faculty. Just as a man may work out a problem or perform an arithmetical calculation with perfect command of the data and processes involved, but in no way burden his mind with the details, or even the result of his work, if these do not personally con. cern him, he may concentrate attention and bring his reasoning faculties to bear on a subject of study and master its details, so as to obtain a clear comprehension of the whole while he is not registering any impression to form the basis of memory. Indeed, it is a notable circumstance that in a large class of minds the faculty of apprehension is developed, so to say, at the cost of that of mental registration or memory, the whole force of the intellect being, as it were, expended in understanding, while the storing of impressions is left to chance, which generally means that it is wholly neglected. It is therefore important to bear in mind that a quick understanding does not either involve or imply an aptitude for study. It is simply an effective power of perception, and is not uncommonly associated with a proneness to forget, which is in truth the effect of an absence or inefficiency of the faculty of mental recording. The distinctness and almost antagonism of these two functions of the mind, understanding and memory, is curiously apparent in the fact that idiots have often extraordinary powers of retention and recollection, while the most intelligent hearers and readers often find to their cost that they are the most forgetful. The student should not allow the consciousness he may have of a quick understanding to encourage him in the neglect to cultivate his memory, or be misled by a "good memory" to assume that he is endowed with high intellectual ability. It is, undoubtedly, possible that the mind may be duly charged with a record of any subject or any information, and be unable to remember it at will. This circumstance arises from the fact that memory concerns the method of recording rather than the record itself. A piece of know-
doi:10.1016/s0140-6736(02)47831-2 fatcat:vi2hcgw76jehdg22dblafmfcfu