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Discovering Diverse Content Through
Random Scribd Documents
The Project Gutenberg eBook of
Use of the Dead to the Living
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
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you are located before using this eBook.

Title: Use of the Dead to the Living

Author: Southwood Smith

Release date: December 12, 2018 [eBook #58460]

Language: English

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*** START OF THE PROJECT GUTENBERG EBOOK USE OF THE

DEAD TO THE LIVING ***
 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.
It would be leading to a detail which is incompatible with our
present purpose to follow these speculations, or to give an account
of the doctrines of the mechanical physicians, who believed that
every operation of the animal economy was explained by comparing
it to a system of ropes, levers, and pulleys, united with a number of
rigid tubes of different lengths and diameters, containing fluids
which, from variations in their impelling causes, moved with different
degrees of velocity: or of the chemical physicians, whose manner of
theorizing and investigating would have qualified them better for the
occupation of the brewer or of the distiller, than for that of the
physician. All these speculations are idle fancies, without any
evidence whatever to support them; and it has been argued that, for
this very reason, they must have been without any practical result,
and that, therefore, if they were productive of no benefit, they were,
at least, innoxious. No opinion can be more false or pernicious.
These wretched theories not only pre occupied the mind, prevented
it from observing the real phenomena of health and of disease, and
the actual effect of the remedies which were employed, and thus put
an effectual stop to the progress of the science: but they were
productive of the most direct and serious evils. It is no less true in
medicine than in philosophy and morals, that there is no such thing
as innoxious error; that men's opinions invariably influence their
conduct; and that physicians, like other men, act as they think.
Asclepiades, whose mind was full of corpuscles and interstices, was
intent on finding suitable remedies, which he discovered in
gestation, friction, and the use of wine. By various exercises, he
proposed to render the pores more open, and to make the juices
and corpuscles, the retention of which causes disease, to pass more
freely. Hence he used gestation from the very beginning of the most
burning fevers. He laid it down as a maxim, that one fever was to be
cured by another; that the strength of the patient was to be
exhausted by making him watch and endure thirst to such a degree,
that for the first two days of the disorder he would not allow them to
cool their mouths with a drop of water. Abernethy's regulated diet is
luxurious compared to his plan of abstinence. For the three first days
he allowed his patients no aliment whatever; on the fourth, he so far
relented as to give to some of them a small portion of food; but
from others he absolutely withheld all nourishment till the seventh
day. And this is the gentleman who laid it down as a maxim, that all
diseases are to be cured "Tuto, celeriter et jucunde." To be sure he
was a believer in the doctrine of compensation; and in the latter
stage of their diseases endeavored to recompense his patients for
the privations he caused them to endure in the beginning of their
illness. Celsus observes, that though he treated his patients like a
butcher during the first days of the disorder, he afterwards indulged
them so far as to give directions for making their beds in the softest
manner. He allowed them abundance of wine, which he gave freely
in all fevers; he did not forbid it even to those afflicted with phrenzy:
nay, he ordered them to drink it till they were intoxicated; for, said
he, it is absolutely necessary that persons who labor under phrenzy
should sleep, and wine has a narcotic quality. To lethargic patients,
he prescribed it with great freedom, but with the opposite purpose
of rousing them from their stupor. His great remedy in dropsy was
friction, which, of course, he employed to open the pores. With the
same view, he enjoined active exercise to the sick; but what is a
little extraordinary, he denied it to those in health.
Eristratus, who was a great speculator, and whose theories had the
most important influence on his practice, banished blood-letting
altogether from medicine, for the following notable reasons:
because, he says, we cannot always see the vein we intend to open;
because we are not sure we may not open an artery instead of a
vein; because we cannot ascertain the true quantity to be taken;
because, if we take too little, the intention is not answered; if too
much, we may destroy the patient; and because the evacuation of
the venous blood is succeeded by that of the spirits, which thus pass
from the arteries into the veins; wherefore, blood-letting ought
never to be used as a remedy in disease. Yet, though he was thus
cautious in abstracting blood, it must not be supposed that he was
not a sufficiently bold practitioner. In tumor of the liver, he hesitated
not to cut open the abdomen, and to apply his medicines
immediately to the diseased organ; but though he took such liberties
with the liver, he regarded with the greatest apprehension the
operation of tapping in dropsy of the abdomen: because, said he,
the waters being evacuated, the liver which is inflamed and become
hard like a stone, is more pressed by the adjacent parts, which the
waters kept at a distance from it, whence the patient dies.
One physician conceived that gout originated from an effervescence
of the synovia of the joints with the vitriolated blood: whence he
recommended alcohol for its cure: a remedy for which the court of
aldermen ought to have voted him a medal. A more ancient
practitioner, who believed that the finger of St. Blasius was very
efficacious "for removing a bone which sticks in the throat,"
maintained that gout was the "grand drier," and prescribed a remedy
for it, which the patient was to use for a whole year, and to observe
the following diet each month. In September, he must eat and drink
milk; in October, he must eat garlic; in November, he is to abstain
from bathing; in December, he must eat no cabbage; in January, he
is to take a glass of pure wine in the morning; in February, to eat no
beef; in March, to mix several things both in eatables and
drinkables; in April, not to eat horse-radish; nor in May, the fish
called Polypus; in June, he is to drink cold water in a morning; in
July, to avoid venery; and lastly, in August, to eat no mallows.
A third physician deduced all diseases from inspissation of the fluids;
hence he attached the highest importance to diluent drinks, and
believed that tea, especially, is a sovereign remedy in almost every
disease to which the human frame is subject; "tea," says Bentekoe,
who is loudest in his praises of this panacea, and who, as
Blumenbach observes, 'deserved to have been pensioned by the
East India Company for his services,' "tea is the best, nay, the only
remedy for correcting viscidity of the blood, the source of all
diseases, and for dissipating the acid of the stomach, as it contains a
fine oleaginous volatile salt, and certain subtle spirits which are
analogous in their nature to the animal spirits. Tea fortifies the
memory and all the intellectual faculties: it will therefore furnish the
most effectual means of improving physical education. Against fever
there is no better remedy than forty or fifty cups of tea, swallowed
immediately after one another, the slime of the pancreas is thus
carried off."
Another physician derived all his diseases from a redundancy or
deficiency of fire and water. He maintained that where the water
predominated, the fluids became viscid, and that hence arose
intermittent fevers and arthritic complaints. His remedies are in strict
conformity to his theory. These diseases are to be cured by volatile
salts, which abound with fiery particles; venesection in any case is
highly pernicious; these fiery medicines are the only efficacious
remedies, and are to be employed even in diseases of the most
inflammatory nature. "Life," says Dr. Brown, "is a forced state;" it is
a flame kept alive by excitement; every thing stimulates; some
substances too violently; others not sufficiently; there are thus two
kinds of debility, indirect and direct, and to one or other of these
causes must be referred the origin of all diseases. According to this
doctrine, the mode of cure is simple: we have nothing to do but to
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