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USE OF THE DEAD
TO THE
LIVING.
FROM THE WESTMINSTER REVIEW.
_ALBANY_:
PRINTED BY WEBSTERS AND SKINNERS.
1827.
ADVERTISEMENT.
The following pages contain an article extracted from the Westminster
Review, an English periodical of considerable reputation. On its
appearance in Great Britain, it excited great attention; and, indeed,
has been there reprinted in a cheap form for general distribution. The
author (Dr. SOUTHWOOD SMITH) deserves the thanks of the community for
the talents he has displayed, and the lucid and powerful manner in which
he has investigated the important subject under consideration.
The editors believe that they are discharging a duty to the community in
presenting it to them for perusal and consideration. They will not
conceal their wishes, that it may have a favorable effect on a bill now
pending before the Legislature. Both in a general point of view, as well
as with reference to the particular institution to be benefitted, the
arguments are particularly applicable; nor will an enlightened body of
men be deterred from doing what they may deem their duty by the
unparalleled impudence of those who _now_ cry out against monopoly, when
they have risen into importance by monopoly, and have, always, while it
suited their views, been its most persecuting and vindictive advocates.
It is due to truth to state, that the suggestion of the republication of
this article, originated with a member of the Senate of this state, and
who does not belong to the profession.
_February, 1827._
USE OF THE DEAD TO THE LIVING.
FROM THE WESTMINSTER REVIEW.
_An Appeal to the Public and to the Legislature, on the necessity
of affording Dead Bodies to the Schools of Anatomy, by Legislative
Enactment._ By WILLIAM MACKENZIE. Glasgow. 1824.
Every one desires to live as long as he can. Every one values health
"above all gold and treasure." Every one knows that as far as his own
individual good is concerned, protracted life and a frame of body sound
and strong, free from the thousand pains that flesh is heir to, are
unspeakably more important than all other objects, because life and
health must be secured before any possible result of any possible
circumstance can be of consequence to him. In the improvement of the art
which has for its object the preservation of health and life, every
individual is, therefore, deeply interested. An enlightened physician
and a skilful surgeon, are in the daily habit of administering to their
fellow men more real and unquestionable good, than is communicated, or
communicable by any other class of human beings to another. Ignorant
physicians and surgeons are the most deadly enemies of the community:
the plague itself is not so destructive; its ravages are at distant
intervals, and are accompanied with open and alarming notice of its
purpose and power; theirs are constant, silent, secret; and it is while
they are looked up to as saviours, with the confidence of hope, that
they give speed to the progress of disease and certainty to the stroke
of death.
It is deeply to be lamented that the community, in general, are so
entirely ignorant of all that relates to the art and the science of
medicine. An explanation of the functions of the animal economy; of
their most common and important deviations from the healthy state; of
the remedies best adapted to restore them to a sound condition, and of
the mode in which they operate, as far as that is known, ought to form a
part of every course of liberal education. The profound ignorance of the
people on all these subjects, is attended with many disadvantages to
themselves, and operates unfavorably on the medical character. In
consequence of this want of information, persons neither know what are
the attainments of the man in whose hands they place their life, nor
what they ought to be; they can neither form an opinion of the course of
education which it is incumbent on him to follow, nor judge of the
success with which he has availed himself of the means of knowledge
which have been afforded him. There is one branch of medical education
in particular, the foundation, in fact, on which the whole
superstructure must be raised, the necessity of which is not commonly
understood, but which requires only to be stated to be perceived.
Perhaps it is impossible to name any one subject which it is of more
importance that the community should understand. It is one in which
every man's life is deeply implicated: it is one on which every man's
ignorance or information will have a considerable influence. We shall,
therefore, enter into it with some detail: we shall show the kind of
knowledge which it is indispensable that the physician and surgeon
should possess; we shall illustrate, by a reference to particular cases,
the reason why this kind of knowledge cannot be dispensed with: and we
shall explain, by a statement of facts, the nature and extent of the
obstacles which at present oppose the acquisition of this knowledge. We
repeat, there is no subject in which every reader can be so immediately
and deeply interested, and we trust that he will give us his calm and
unprejudiced attention.
The basis of all medical and surgical knowledge is anatomy. Not a single
step can be made either in medicine or surgery, considered either as an
art or a science without it. This should seem self evident, and to need
neither proof nor illustration: nevertheless, as it is useful
occasionally to contemplate the evidence of important truth, we shall
show why it is, that there can be no rational medicine, and no safe
surgery, without a thorough knowledge of anatomy.
Disease, which it is the object of these arts to prevent and to cure, is
denoted by disordered function: disordered function cannot be understood
without a knowledge of healthy function; healthy function cannot be
understood without a knowledge of structure; structure cannot be
understood unless it be examined.
The organs on which all the important functions of the human body
depend, are concealed from the view. There is no possibility of
ascertaining their situation and connections, much less their nature and
operation, without inspecting the interior of this curious and
complicated machine. The results of the mechanism are visible; the
mechanism itself is concealed, and must be investigated to be perceived.
The important operations of nature are seldom entirely hidden from the
human eye; still less are they obtruded upon it, but over the most
curious and wonderful operations of the animal economy so thick a veil
is drawn, that they never could have been perceived without the most
patient and minute research. The circulation of the blood, for example,
never could have been discovered without dissection. Notwithstanding the
partial knowledge of anatomy which must have been acquired by the
accidents to which the human body is exposed, by attention to wounded
men, by the observance of bodies killed by violence; by the huntsman in
using his prey; by the priest in immolating his victims; by the augur in
pursuing his divinations; by the slaughter of animals; by the dissection
of brutes; and even occasionally by the dissection of the human body,
century after century passed away, without a suspicion having been
excited of the real functions of the two great systems of vessels,
arteries and veins. It was not until the beginning of the 17th century,
when anatomy was ardently cultivated, and had made considerable
progress, that the valves of the veins and of the heart were discovered,
and subsequently that the great Harvey, the pupil of the anatomist who
discovered the latter, by inspecting the structure of these valves; by
contemplating their disposition; by reasoning upon their use, was led to
suspect the course of the blood, and afterwards to demonstrate it.
Several systems of vessels in which the most important functions of
animal life are carried on--the absorbent system, for example, and even
that portion of it which receives the food after it is digested, and
which conveys it into the blood, are invisible to the naked eye, except
under peculiar circumstances: whence it must be evident, not only that
the interior of the human body must be laid open, in order that its
organs may be seen; but that these organs must be minutely and patiently
dissected, in order that their structure may be understood.
The most important diseases have their seat in the organs of the body;
an accurate acquaintance with their situation is, therefore, absolutely
necessary, in order to ascertain the seats of disease; but for the
reasons already assigned, their situation cannot be learnt, without the
study of anatomy. In several regions, organs the most different in
structure and function are placed close to each other. In what is termed
the epigastric region, for example, are situated the stomach, the liver,
the gall bladder, the first portion of the small intestine, (the
duodenum) and a portion of the large intestine (the colon); each of
these organs is essentially different in structure and in use, and is
liable to distinct diseases. Diseases the most diversified, therefore,
requiring the most opposite treatment, may exist in the same region of
the body; the discrimination of which is absolutely impossible, without
that knowledge which the study of anatomy alone can impart.
The seat of pain is often at a great distance from that of the affected
organ. In disease of the liver, the pain is generally felt at the top of
the right shoulder. The right phrenic nerve sends a branch to the liver:
the third cervical nerve, from which the phrenic arises, distributes
numerous branches to the neighborhood of the shoulder: thus is
established a nervous communication between the shoulder and the liver.
This is a fact which nothing but anatomy could teach, and affords the
explanation of a symptom which nothing but anatomy could give. The
knowledge of it would infallibly correct a mistake, into which a person
who is ignorant of it, would be sure to fall: in fact, persons ignorant
of it do constantly commit the error. We have know several instances in
which organic disease of the liver has been considered, and treated as
rheumatism of the shoulder. In each of these cases, disease in a most
important organ might have been allowed to steal on insidiously, until
it became incurable; while a person, acquainted with anatomy, would have
detected it at once, and cured it without difficulty. Many cases have
occurred of persons who have been supposed to labor under disease of the
liver, and who have been treated accordingly: on examination after
death, the liver has been found perfectly healthy, but there has been
discovered extensive disease of the brain. Disease of the liver is often
mistaken for disease of the lungs: on the other hand, the lungs have
been found full of ulcers, when they were supposed to have been
perfectly sound, and when every symptom was referred to disease of the
liver. Persons are constantly attacked with convulsions--children
especially; convulsions are spasms: spasms, of course, are to be treated
by antispasmodics. This is the notion amongst people ignorant of
medicine: it is the notion amongst old medical men: it is the notion
amongst half educated young ones. All this time these convulsions are
merely a symptom; that symptom depends upon, and denotes, most important
disease in the brain: the only chance of saving life, is the prompt and
vigorous application of proper remedies to the brain; but the
practitioner whose mind is occupied with the symptom, and who prescribes
antispasmodics, not only loses the time in which alone any thing can be
done to snatch the victim from death, but by his remedies absolutely
adds fuel to the flame which is consuming his patient. In disease of the
hip-joint pain is felt, not in the hip, but, in the early stage of the
disease, at the knee. This also depends on nervous communication. The
most dreadful consequences daily occur from an ignorance of this single
fact. In all these cases error is inevitable, without a knowledge of
anatomy: it is scarcely possible with it: in all these cases error is
fatal: in all these cases anatomy alone can prevent the error--anatomy
alone can correct it. Experience, so far from leading to its detection,
would only establish it in men's minds, and render its removal
impossible. What is called experience is of no manner of use to an
ignorant and unreflecting practitioner. In nothing does the adage, that
it is the wise only who profit by experience, receive so complete an
illustration as in medicine. A man who is ignorant of certain
principles, and who is incapable of reasoning in a certain manner, may
have daily before him for fifty years cases affording the most complete
evidence of their truth, and of the importance of the deduction to which
they lead, without observing the one, or deducing the other. Hence the
most profoundly ignorant of medicine, are often the oldest members of
the profession, and those who have had the most extensive practice. A
medical education, founded on a knowledge of anatomy, is, therefore, not
only indispensable to prevent the most fatal errors, but to enable a
person to obtain advantage from those sources of improvement which
extensive practice may open to him.
To the surgeon, anatomy is eminently what Bacon has so beautifully said
that knowledge in general is: it is power--it is power to lessen pain,
to save life, and to eradicate diseases, which, without its aid, would
be incurable and fatal. It is impossible to convey to the reader a clear
conception of this truth, without a reference to particular cases; and
the subject is one of such extreme importance, that it may be worth
while to direct the attention for a moment to two or three of the
capital diseases which the surgeon is daily called upon to treat.
Aneurism, for example, is a disease of an artery, and consists of a
preternatural dilatation of its coats. This dilatation arises from the
debility of the vessel, whence, unable to resist the impetus of the
blood, it yields, and is dilated into a sac. When once the disease is
induced, it commonly goes on to increase with a steady and uninterrupted
progress, until at last it suddenly bursts, and the patient expires
instantaneously from loss of blood. When left to itself, it almost
uniformly proves fatal in this manner; yet, before the time of Galen, no
notice was taken of this terrible malady. The ancients, indeed, who
believed that the arteries were air tubes, could not possibly have
conceived the existence of an aneurism. Were the number of individuals
in Europe, who are now annually cured of aneurism, by the interference
of art, to be assumed as the basis of a calculation of the number of
persons who must have perished by this disease, from the beginning of
the world to the time of Galen, it would convey some conception of the
extent to which anatomical knowledge is the means of saving human life.
The only way in which it is possible to cure this disease is, to produce
an obliteration of the cavity of the artery. This is the object of the
operation. The diseased artery is exposed, and a ligature is passed
around it, above the dilatation, by means of which the blood is
prevented from flowing into the sac, and inflammation is excited in the
vessel; in consequence of which its sides adhere together, and its
cavity becomes obliterated. The success of the operation depends
entirely on the completeness of the adhesion of the sides of the vessel,
and the consequent obliteration of its cavity. This adhesion will not
take place unless the portion of the artery to which the ligature is
applied be in a sound state. If it be diseased, as it almost always is
near the seat of the aneurism, when the process of nature is completed
by which the ligature is removed, hemorrhage takes place, and the
patient dies just as if the aneurism had been left to itself. For a long
time the ligature was applied as close as possible to the seat of the
aneurism: the aneurismal sac was laid open in its whole extent, and the
blood it contained was scooped out. The consequence was, that a large
deep-seated sore, composed of parts in an unhealthy state, was formed:
it was necessary to the cure that this sore should suppurate, granulate,
and heal: a process which the constitution was frequently unable to
support. Moreover, there was a constant danger that the patient would
perish from hemorrhage, through the want of adhesion of the sides of the
artery. The profound knowledge of healthy and of diseased structure, and
of the laws of the animal economy by which both are regulated, which
John Hunter had acquired from anatomy, suggested to this eminent man a
mode of operating, the effect of which, in preserving human life, has
placed him high in the rank of the benefactors of his race. This
consummate anatomist saw, that the reason why death so often followed
the common operation was, because that process which was essential to
his success was prevented by the diseased condition of the artery. He
perceived that the vessel, at some distance from the aneurism, was in a
sound state; and conceived, that if the ligature were applied to this
distant part, that is, to a sound instead of a diseased portion of the
artery, this necessary process would not be counteracted. To this there
was one capital objection, that it would often be necessary to apply the
ligature around the main trunk of an artery, before it gives off its
branches, in consequence of which the parts below the ligature would be
deprived of their supply of blood, and would therefore mortify. So
frequent and great are the communications between all the arteries of
the body, however, that he thought it probable, that a sufficient
supply would be borne to these parts through the medium of collateral
branches. For an aneurism in the ham, he, therefore, boldly cut down
upon the main trunk of the artery which supplies the lower extremity;
and applied a ligature around it, where it is seated near the middle of
the thigh, in the confident expectation that, though he thus deprived
the limb of the supply of blood which it received through its direct
channel, it would not perish. His knowledge of the processes of the
animal economy, led him to expect that the force of the circulation
being thus taken off from the aneurismal sac, the progress of the
disease would be stopped; that the sac itself, with all its contents,
would be absorbed; that by this means the whole tumor would be removed,
and that an opening into it would be unnecessary. The most complete
success followed this noble experiment, and the sensations which this
philosopher experienced when he witnessed the event, must have been
exquisite, and have constituted an appropriate reward for the
application of profound knowledge to the mitigation of human suffering.
After Hunter followed Abernethy, who, treading in the footsteps of his
master, for an aneurism of the femoral, placed a ligature around the
external iliac artery; lately the internal iliac itself has been taken
up, and surgeons have tied arteries of such importance, that they have
been themselves astonished at the extent and splendor of their success.
Every individual, on whom an operation of this kind has been
successfully performed, is snatched by it from certain and inevitable
death!
The symptom by which an aneurism is distinguished from every other tumor
is, chiefly its pulsating motion. But when an aneurism has become very
large, it ceases to pulsate; and when an abscess is seated near an
artery of great magnitude, it acquires a pulsating motion; because the
pulsations of the artery are perceptible through the abscess. The real
nature of cases of this kind cannot possibly be ascertained, without a
most careful investigation, combined with an exact knowledge of the
structure and relative position of all the parts in the neighborhood of
the tumor. Pelletan, one of the most distinguished surgeons of France,
was one day called to a man who, after a long walk, was seized with a
severe pain in the leg, over the seat of which appeared a tumor, which
was attended with a pulsation so violent that it lifted up the hand of
the examiner. There seemed every reason to suppose that the case was an
aneurismal swelling. This acute observer, however, in comparing the
affected with the sound limb, perceived in the latter a similar
throbbing. On careful examination he discovered that, by a particular
disposition in this individual, one of the main arteries of the leg (the
anterior tibial) deviated from its usual course, and instead of
plunging deep between the muscles, lay immediately under the skin and
fascia. The truth was, that the man in the exertion of walking, had
ruptured some muscular fibres, and the uncommon distribution of the
artery gave to this accident these peculiar symptoms. The real nature of
this case could not possibly have been ascertained but by an anatomist.
The same surgeon has recorded the case of a man who, having fallen twice
from his horse, and experienced for several years considerable
uneasiness in his back, was afflicted with acute pain in the abdomen. At
the same time an oval, irregularly circumscribed tumor made its
appearance in the right flank. It presented a distinct fluctuation, and
had all the appearance of a collection of matter depending on caries of
the vertebræ. The pain was seated chiefly at the lower portion of that
part of the spine which forms the back, which was, moreover, distorted;
and this might have confirmed the opinion that the case was a lumbar
abscess with caries. Pelletan, however, who well knew that an aneurism,
as it enlarges, may destroy any bone in its neighborhood, saw that the
disease was an aneurism, and predicted that the patient must perish. On
opening the body (for the man lived only ten days after Pelletan first
saw him) an aneurismal tumor was discovered, which nearly filled the
cavity of the abdomen. If this case had been mistaken for lumbar
abscess, and the tumor had been opened with a view of affording an exit
to the matter, the man would have died in a few seconds. There is no
surgeon of discernment or experience whose attention has not been
awakened, and whose sagacity has not been put to the test, by the
occurrence of similar cases in his own practice. The consequence of
error is almost always instantaneously fatal. The catalogue of such
disastrous events is long and melancholy. Richerand has recorded, that
Ferrand, head surgeon of the Hotel Dieu, mistook an aneurism in the
armpit for an abscess; plunged his knife into the swelling, and killed
the patient. De Haen speaks of a person who died in consequence of an
opening which was made, contrary to the advice of Boerhaave in a similar
tumor at the knee. Vesalius was consulted about a tumor in the back,
which he pronounced to be an aneurism; but an ignorant practitioner
having made an opening into it, the patient instantly bled to death.
Nothing can be more easy than to confound an aneurism of the artery of
the neck with the swelling of the glands in its neighborhood: with a
swelling of the cellular substance which surrounds the artery; with
abscesses of various kinds; but if a surgeon were to fall into this
error, and to open a carotid aneurism, his patient would certainly be
dead in the space of a few moments. It must be evident, then, that a
thorough knowledge of anatomy is not only indispensable to the proper
treatment of cases of this description, but also to the prevention of
the most fatal mistakes.
There is nothing in surgery of more importance than the proper treatment
of hemorrhage. Of the confusion and terror occasioned by the sight of a
human being from whom the blood is gushing in torrents, and whose
condition none of the spectators is able to relieve, no one can form an
adequate conception, but those who have witnessed it. In all such cases,
there is one thing proper to be done, the prompt performance of which is
generally as certainly successful, as the neglect of it is inevitably
fatal. It is impossible to conceive of a more terrible situation than
that of a medical man who knows not what to do on such an emergency. He
is confused; he hesitates: while he is deciding what measures to adopt,
the patient expires: he can never think of that man's death without
horror, for he is conscious that, but for his ignorance, he might have
averted his patient's fate. The ancient surgeons were constantly placed
in this situation, and the dread inspired by it retarded the progress of
surgery more than all other causes put together. Not only were they
terrified from interfering with the most painful and destructive
diseases, which experience has proved to be capable of safe and easy
removal, but they were afraid to cut even the most trivial tumor. When
they ventured to remove a part, they attempted it only by means of the
ligature, or by the application of burning irons. When they determined
to amputate, they never thought of doing so until the limb had
mortified, and the dead had separated from the living parts; for they
were absolutely afraid to cut into the living flesh. They had no means
of stopping hemorrhage, but by the application of astringents to the
bleeding vessels, remedies which were inert; or of burning irons, or
boiling turpentine, expedients which were not only inert but cruel.
Surgeons now know that the grand means of stopping hemorrhage is
compression of the bleeding vessel. If pressure be made on the trunk of
an artery, though blood be flowing from a thousand branches given off
from it, the bleeding will cease. Should the situation of the artery be
such as to allow of effectual external pressure, nothing further is
requisite: the pressure being applied, the bleeding is stopped at once:
should the situation of the vessel place it beyond the reach of external
pressure, it is necessary to cut down upon it, and to secure it by the
application of a ligature. Parè may be pardoned for supposing that he
was led to the discovery of this invaluable remedy by the inspiration of
the Deity. By means of it the most formidable operations may be
undertaken with the utmost confidence, because the wounded vessels can
be secured the moment they are cut: by the same means the most
frightful hemorrhages may be most effectually stopped: and even when the
bleeding is so violent as to threaten immediate death, it may often be
averted by the simple expedient of placing the finger upon the wounded
vessel, until there is time to tie it. But it is obvious that none of
these expedients can be employed, and that these bleedings can neither
be checked at the moment, nor permanently stopped, without such a
knowledge of the course of the trunks and branches of vessels, as can be
acquired only by the study of anatomy.
The success of amputation is closely connected with the knowledge of the
means of stopping hemorrhage. Not to amputate is often to abandon the
patient to a certain and miserable death. And all that the surgeon
formerly did, was to watch the progress of that death: he had no power
to stop or even to retard it. The fate of Sir Philip Sidney is a
melancholy illustration of this truth. This noble minded man, the light
and glory of his age, was cut off in the bloom of manhood, and the midst
of his usefulness, by the wound of a musket bullet in his left leg, a
little above the knee, "when extraction of the ball, or amputation of
the limb," says his biographer, "would have saved his inestimable life:
but the surgeons and physicians were unwilling to practice the one, and
knew not how to perform the other. He was variously tormented by a
number of surgeons and physicians for three weeks." Amputation indeed
was never attempted, except where mortification had itself half
performed the operation. The just apprehension of an hemorrhage which
there was no adequate means of stopping, checked the hand of the boldest
surgeon, and quailed the courage of the most daring patient--and if ever
the operation was resorted to, it almost always proved fatal: the
patient generally expired, according to the expression of Celsus, "_in
ipso opere_." How could it be otherwise? The surgeon cut through the
flesh of his patient with a red hot knife: this was his only means of
stopping the hemorrhage: by this expedient he sought to convert the
whole surface of the stump into an eschar: but this operation, painful
in its execution, and terrible in its consequences, when it even
appeared to succeed, succeeded only for a few days; for the bleeding
generally returned, and proved fatal as soon as the sloughs or dead
parts became loose. Plunging the stump into boiling oil, into boiling
turpentine, into boiling pitch, for all these means were used, was
attended with no happier result, and after unspeakable suffering, almost
every patient perished. In the manner in which amputation is performed
at present, not more than one person in twenty loses his life in
consequence of the operation, even taking into the account all the cases
in which it is practised in hospitals. In private practice, where many
circumstances favor its success, it is computed that 95 persons out of
100 recover from it, when it is performed at a proper time, and in a
proper manner. It seems impossible to exhibit a more striking
illustration of the great value of anatomical knowledge.
But if there be any disease, which, from the frequency of its
occurrence, from the variety of its forms, from the difficulty of
discriminating between it and other maladies, and from the danger
attendant on almost all its varieties, requires a combination of the
most minute investigation, with the most accurate anatomical knowledge,
it is that of hernia. This disease consists of a protrusion of some of
the viscera of the abdomen, from the cavity in which they are naturally
contained, into a preternatural bag, composed of the portion of the
peritoneum (the membrane which lines the abdomen) which is pushed before
them. It is computed that one sixteenth of the human race are afflicted
with this malady. It is sometimes merely an inconvenient complaint,
attended with no evil consequences whatever; but there is no form of
this disease, which is not liable to be suddenly changed, and by slight
causes, from a perfectly innocent state, into a condition which may
prove fatal in a few hours. The disease itself occurs in numerous
situations; it may be confounded with various diseases; it may exist in
the most diversified states; it may require, without the loss of a
single moment, a most important and delicate operation; and it may
appear to demand this operation, while the performance of it may really
be not only useless, but highly pernicious.
The danger of hernia depends on its passing into that state which is
technically termed strangulation. When a protruded intestine suffers
such a degree of pressure, as to occasion a total obstruction to the
passage of its contents, it is said to be strangulated. The consequence
of pressure thus producing strangulation is, the excitement of
inflammation: this inflammation must inevitably prove fatal, unless the
pressure be promptly removed. In most cases, this can be effected only
by the operation. Two things, then, are indispensable: first, the
ability to ascertain that the symptoms are really produced by pressure,
that is, to distinguish the disease from the affections which resemble
it; and secondly, when this is effected, to perform the operation with
promptitude and success. The distinction of strangulated hernia from
affections which resemble it, often requires the most exact knowledge
and the most minute investigation. The intestine included in a hernial
sac, may be merely affected with colic, and thus give rise to the
appearance of strangulation. It may be in a state of irritation,
produced, for example, by unusual fatigue; and from this cause, may be
attacked with the symptoms of inflammation. Inflammation may be excited
in the intestine, by the common causes of inflammation, which the hernia
may have no share in inducing, and of which it may not even participate.
Were this case mistaken, and the operation performed, it would not only
be useless, but pernicious: while the attention of the practitioner
would be diverted from the real nature of the malady; the prompt and
vigorous application of the remedies which alone could save the patient,
would be neglected, and he would probably perish. On the other hand, a
very small portion of intestine may become strangulated, and urgently
require the operation. But there may be no tumor; all the symptoms may
be those, and, on a superficial examination, only those, of inflammation
of the bowels. Were the real nature of this case mistaken, death would
be inevitable. Nothing is more common than fatal errors of this kind. It
is only a few months ago, that a physician was called in haste to a
person who was said to be dying of inflammation of the bowels. Before he
reached the house the man was dead. He had been ill only three days. On
looking at the abdomen, there was a manifest hernia: the first glance
was sufficient to ascertain the fact. The practitioner in attendance had
known nothing of the matter; he had never suspected the real nature of
the disease, and had made no inquiry which could have led to the
detection of it. Here was a case which might probably have been saved,
but for the criminal ignorance and inattention of the practitioner.
Whenever there are symptoms of inflammation of the bowels, examination
of the abdomen is indispensable: and the life of the patient will depend
on the care and accuracy with which the investigation is made.
But it is possible that inflammation may attack the parts included in
the hernial sac, without arising from the hernia itself. The
inflammation may be produced by the common causes of inflammation; there
may be no pressure: there may be no strangulation: the swelling may be
the seat, not the cause of the disease. In this case, too, the operation
would be both useless and pernicious. Now all these are diversities
which it is of the highest importance to discriminate. In some of them,
life depends on the clearness, accuracy, and promptitude, with which the
discrimination is made. Promptitude is of no less consequence than
accuracy. If the decision be not formed and acted on at once, it will be
of no avail. The rapidity of the progress of this disease is often
frightful. We have mentioned a case in which it was fatal in three days,
but it not unfrequently terminates fatally in less than twenty four
hours. Sir Astley Cooper mentions a case in which the patient was dead
in eight hours after the commencement of the disease. Larrey has
recorded the case of a soldier in whom a hernia took place, which was
strangulated immediately. He was brought to the "ambulance" instantly,
and perished in two hours with gangrene of the part, and of the
abdominal viscera. This was the second instance which had occurred to
this surgeon of a rapidity thus appalling. What clearness of judgment,
what accuracy of knowledge, what promptitude of decision, are necessary
to treat such a disease with any chance of success!
The moment that a case is ascertained to be strangulated hernia, an
attempt must be made to liberate the parts from the stricture, and to
replace them in their natural situation. This is first attempted by the
hand, and the operation is technically termed the _taxis_. The patient
must be placed in a particular position; pressure must be made in a
particular direction; it is impossible to ascertain either, without an
accurate knowledge of the parts. If pressure be made in a wrong
direction, and in a rough and unscientific manner, the organs protruded
instead of being urged through a proper opening, are bruised against the
parts which oppose their return. Many cases are on record, in which
gangrene and even rupture of the intestine, have been occasioned in this
manner. When the parts cannot be returned by the hand, assisted by those
remedies which experience has proved to be beneficial, the operation
must be performed without the delay of a moment. To its proper
performance two things are necessary. First, a minute anatomical
knowledge of the various and complicated parts which are implicated in
it; and secondly, a steady, firm, and delicate command of the knife. In
the first place, the integuments must be divided; the cellular substance
which intervenes between the skin and the hernial sac must be removed
layer by layer with the knife and the dissecting forceps; the sac itself
must be opened: this part of the operation must be performed with the
most extreme caution: the sac being laid open, the protruded organs are
now exposed to view. The operator must next ascertain the exact point
where the stricture exists; having discovered its seat, he must make his
incision with a particular instrument--in a certain direction--to a
definite extent. On account of the nature of the parts implicated in the
operation, and the proximity of vessels, life depends on an exact
knowledge and a precise and delicate attention to all these
circumstances. How can this knowledge be obtained, how can this
dexterity be acquired, without a profound acquaintance with anatomy, and
how can this be acquired without frequent and laborious dissection? The
eye must become familiar with the appearance of the integuments, with
the appearance of the cellular substance beneath it, with the
appearance of the hernial sac, and of the changes which it undergoes by
disease; with the appearance of the various viscera contained in it, and
of their changes: and the hand must pay that steady and prompt obedience
to the judgment, which nothing but knowledge, and the consciousness of
knowledge, can command. Even this is not all. When the operation has
been performed thus far with perfect skill and success, the most
opposite measures are required according to the actual state of the
organs contained in the sac. If they are agglutinated together--if
portions of them are in a state of mortification, to return them into
the cavity of the abdomen in that condition, would, in general, be
certain death. Preternatural adhesion must be removed; mortified
portions must be cut away: but how can this possibly be done without an
acquaintance with healthy and diseased structure, and how can this be
obtained without dissecting the organs in a state of health and of
disease?
It has been stated that the progress of strangulated hernia to a fatal
termination is often frightfully rapid; in certain cases to delay the
operation, even for a very short period, is, therefore, to lose the only
chance of success. But ignorant and half informed surgeons are afraid to
operate. They are conscious that the operation is one of immense
importance: they know that in the hands of an operator ignorant of
anatomy, it is one of extreme hazard: they therefore put off the time as
long as possible: they have recourse to every expedient: they resort to
every thing but the only efficient remedy, and when at last they are
compelled by a secret sense of shame to try that, it is too late. All
the best practical surgeons express themselves in the strongest language
on the importance of performing the operation early, if it be performed
at all. On this point there is a perfect accordance between the most
celebrated practitioners on the continent, and the great surgeons of our
own country: all represent, in many parts of their writings, the
dangerous and fatal effects of delay. Mr. Hey in his Practical
Observations, states that when he first began to practice, he considered
the operation as the last resource, and only to be employed when the
danger appeared imminent. "By this dilatory mode of practice," says he,
"I lost three patients in five, upon whom the operation was performed.
Having more experience of the urgency of the disease, I made it my
custom, when called to a patient who had laboured two or three days
under the disease, to wait only about two hours, that I might try the
effect of bleeding (if that evacuation was not forbidden by some
peculiar circumstance of the case) and the tobacco clyster. In this mode
of practice, I lost about two patients in nine, upon whom I operated.
This comparison is drawn from cases nearly similar, leaving out of the
account those cases in which gangrene of the intestine had taken place.
I have now, at the time of writing this, performed the operation
thirty-five times; and have often had occasion to lament that I
performed it too late, but never that I had performed it too soon."
These observations are sufficient to show the importance of anatomy in
certain surgical diseases. The state of medical opinion from the
earliest ages to the present time, furnishes a most instructive proof of
its necessity to the detection and cure of disease in general. The
doctrines of the father of physic were in the highest degree vague and
unmeaning. Every thing is resolved by Hippocrates into a general
principle, which he terms nature; and to which he ascribes intelligence;
which he clothes with the attributes of justice; and which he represents
as possessing virtues and powers, which he says are her servants, and by
means of which she performs all her operations in the bodies of animals,
distributes the blood, spirits, and heat, through all the parts of the
body, and imparts to them life and sensation. He states that the manner
in which she acts, is by attracting what is good or agreeable to each
species, and retaining, preparing, and changing it: or, on the other
hand, by rejecting whatever is superfluous or hurtful, after she has
separated it from the good. This is the foundation of the doctrine of
depuration, concoction, and crisis in fevers, so much insisted on by
him, and by other physicians after him; but when he explains what he
means by nature, he resolves it into heat, which he says appears to have
something immortal in it.
The great opponent of Hippocrates was Asclepiades. He asserted that
matter, considered in itself, is of an unchangeable nature: that all
perceptible bodies are composed of a number of small ones, termed
corpuscles, between which there are interspersed an infinity of small
spaces totally devoid of matter: that the soul itself is composed of
these corpuscles: that what is called nature is nothing more than matter
and motion: that Hippocrates knew not what he said when he spoke of
nature as an intelligent being, and ascribed to her various qualities
and virtues: that the corpuscles, of which all bodies are composed, are
of different figures, and consist of different assemblages: that all
bodies contain numerous pores, or interstices, which are of different
sizes: that the human body, like all other bodies, possesses pores
peculiar to itself: that these pores are larger or smaller, according as
the corpuscles which pass through them differ in magnitude: that the
blood consists of the largest, and the spirits and the heat of the
smallest. On these principles, Asclepiades founded his theory of
medicine. He maintains, that as long as the corpuscles are freely
received by the pores, the body remains in its natural state: that, on
the contrary, as soon as any obstacle obstructs their passage, it begins
to recede from that state: that, therefore, health depends on the just
proportion between these pores and corpuscles: that, on the contrary,
disease proceeds from a disproportion between them: that the most usual
obstacle arises from a retention of some of the corpuscles in their
ordinary passages, where they arrive in too large a number, or are of
irregular figures, or move too fast or proceed too slow: that phrensies,
lethargies, pleurises, burning fevers for example, are occasioned by
these corpuscles stopping of their own accord: that pain is produced by
the stagnation of the largest of all these corpuscles, of which the
blood consists: that, on the contrary, deliriums, languors,
extenuations, leanness and dropsies, derive their origin from a bad
state of the pores, which are too much relaxed, or opened: that dropsy,
in particular, proceeds from the flesh being perforated with various
small holes, which convert the nourishment received into them into
water: that hunger is occasioned by an opening of the large pores of the
stomach and belly: that thirst arises from an opening of the small
pores: that intermittent fevers have the same origin: that quotidian
fever is produced by a retention of the largest corpuscles; tertian
fever by a retention of corpuscles somewhat smaller; and quartan fever
by a retention of the smallest corpuscles of all.
Galen maintained that the animal body is composed of three principles,
namely, the solids, the humors, and the spirits. That the solid parts
consist of similar and organic: that the humors are four in number,
namely, the blood, the phlegm, the yellow bile, and the black bile: that
the spirits are of three kinds, namely, the vital, the animal, and the
natural: that the vital spirit is a subtle vapour which arises from the
blood, and which derives its origin from the liver, the organ of
sanguification: that the spirits thus formed, are conveyed to the heart,
where, in conjunction with the air drawn into the lungs by respiration,
they become the matter of the second species, namely, of the vital
spirits: that in their turn, the vital spirits are changed into the
animal in the brain, and so on.
At last came Paracelsus, who was believed to have discovered the elixir
of life, and who is the very prince of charlatans. He delivered a course
of lectures on the theory and practice of physic in the University of
Basle, which he commenced by burning the works of Galen and Avicenna in
the presence of his auditory. He assured his hearers, that his
shoe-latchets had more knowledge than both these illustrious authors
put together: that all the academies in the world had not so much
experience as his beard; and that the hair on the back of his neck was
more learned than the whole tribe of authors. It was fitting that a
person of such splendid pretensions should have a magnificent name. He,
therefore, called himself PHILIPPUS AUREOLUS THEOPHRASTUS PARACELSUS
BOMBAST VON HOHENHEIM. He was a great chemist, and like other chemists,
he was a little too apt to carry into other sciences "the smoke and
tarnish of the furnace." He conceived that the elements of the living
system were the same as those of his laboratory, and that sulphur, salt,
and quicksilver, were the constituents of organized bodies. He taught
that these constituents were combined by chemical operations: that their
relations were governed by Archeus, a demon, who performed the part of
alchemist in the stomach, who separated the poisonous from the nutritive
part of the food, and who communicated the tincture by which the food
became capable of assimilation: that this governor of the stomach, this
_spiritus vitæ_, this astral body of man, was the immediate cause of all
diseases, and chief agent in their cure: that each member of the body
had its peculiar stomach, by which the work of secretion was effected:
that diseases were produced by certain influences, of which there were
five in particular, viz. _ens estrale_, _ens veneni_, _ens naturale_,
_ens spirituale_, and _ens deale_: that when Archeus was sick,
putrescence was occasioned, and that either _localiter_ or
_emunctorialiter_, &c. &c. &c.