Part 2

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.