Surgical observations on the constitutional origin and treatment of local diseases; and on aneurisms

Front matter

SURGICAL OBSERVATIONS.

London :

Printed by A. & R. Spottiswoode, New- Street- Square.

Preface

Tfie best mode of obtaining and extending medical and surgical knowledge is, in my opinion, to pay that strict attention to diseases, which qualifies us to note even the slighter shades of difference that distinguish them from each other. Such discrimination leads ns to form some regular arrangement of them, which, even if it be not correct, may ultimately enable us to discover their natural series and order. This method I have pursued from the beginning of my professional studies. Wheneverthe opinions on subjects of importance, which an attention to cases , had impressed upon my mind, differed from those which seemed to prevail amongst other practitioners, I published the facts, and the inferences which I drew from them, because I thought that the former at least deserved attention, and that the latter would either be confirmed or confuted by the result of general experience.

It

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PREFACE.

It is more, however, on account of the cases, than of the conclusions which they suggested, that lam desirous of republishing my surgical writings. Various advantages resulteven from the publication of opinions ; for though we are very liable to error in forming them, yet their promulgation, by exciting investigation, and pointing out the deficiencies of our information, cannot be otherwise than useful in the promotion of science.

The publication of the opinions which naturally arise in the mind of the surgeon, from the cases submitted to his observation, possesses the further utility of rendering a prolix detail of circumstances unnecessary. It wouldbe almost impossible to relate every minute occurrence, that tended to impress certain conclusions on the mind of the observer ; or to relate every trifling particular of treatment, by which the surgeon endeavoured to accomplish his object. Such a dull and tedious narrative, which would weary and disgust the reader, may indeed be well spared ; because the practitioner may, and must, repeatedly peruse the case at large in

the

PREFACE.

Vll the book of nature. The writer merely points out those signs by which any disease may be discriminated from others, and identified as one of the particular class to which he is desirous of exciting the public attention.

With regard to the cases, which I consider as the valuable part of the book, 1 may observe, that it is not to be expected that the records of them will make so strong an impression on the minds of the readers, as the observance of them has done on that of the writer ; but when the same occurrences are met with in practice, then will the impression become more vivid, and knowledge arise, as it usually does, from personal experience. If the facts contained in these volumes occurred so rarely, that others could not be expected to meet with them, their relation would be of little value. They may, however, not improperly be compared to certain species of plants, by no means uncommon, which are liable to be confounded with others by an inattentive observer ; but when their discriminating characters are once pointed out, they may be so

Vlll PREFACE.

so readily distinguished, collected, and examined, as to render a more minute description of them unnecessary. If diseases could, like other objects which we mean to delineate,be placed in various points of view, and illuminated at pleasure, so as to show distinctly their different parts, one accurate representation would suffice; but we see them obscurely, and as knowledge increases, it serves, like light shining from different places, to illuminate the various parts of the objects of our examination.

For, as I have expressed it in the first edition of these writings, “ in proportion as we advance in knowledge, we are led to remark many circumstances in the progress of a disorder which had before passed without notice ; but which, if known and duly attended to, would clearly point out the nature of the complaint. Hence the records of former cases are of much less value; as the symptoms about which we are now anxious to enquire, have in them been entirely overlooked.” It therefore becomes necessary that each writer should state those circumstances to which he has been particularly

attentive ;

PREFACE.

IX attentive ; nor need he further delineate the case than by a general outline, so as to render it intelligible.

The relation of cases may be compared to the representations which an artist gives of natural objects, and which are valuable only in as much as they are correct or vivid delineations of reality. Such portraits, sketched by a person of dull perception or by one whose optics are perverted by prejudice and theory, are either valueless or deceptive ; and hence, perhaps, has arisen that objection to books of cases which I find to be very prevalent. In the imperfect sketches which I have laid before the public, my chief object has been to touch up and bring into view some parts of the subjects which have not been so clearly seen or strongly delineated by former draftsmen.

When books of this kind are published, mutual forbearance is requisite on the part both of the writer and the reader. The lormer should not expect his work to be approved of, till the latter has examined

vol, i. a whether

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whether his representation of diseases be correct, and his conclusions legitimately drawn from the facts which he has observed and collected. Neither should the reader condemn the work till he has examined the subject, and is in consequence able to point out the errors of the premises or conclusions. The author’s view of a subject may indeed be correctly formed from the facts which he himself has witnessed ; but it may differ from that which more extensive experience would have suggested. For this difference no blame can properly be attached to him ; he relates what has fallen under his own observation, and invites others to attend to the same facts.

I have been induced thus to offer my sentiments respecting the design, mode, and probable advantages of recording cases, not with a view of vindicating the plan which I have pursued, for that indeed cannot be necessary, since it is the same that has been followed by the best authors on surgery. My object, by these remarks, has been to induce others to reflect how they may most effectually promote medical

know-

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XI knowledge. No one can have thoroughly studied his profession without perceiving how susceptible it is of improvement, without discerning how inadequate the efforts of an individual must be towards the accomplishment of this purpose, and consequently without feeling an earnest wish to engage general co-operation in this desirable object.

In republishing my former writings, I have left out all that part which relates to physiology. The surgical facts contained in them will now be found incorporated with my later publications, under the same general head of Surgical Observations. I have also made those alterations and enlargements which a greater share of experience has dictated. The subjects have likewise been transposed. I have put at the beginning of the book those cases which show how much local diseases depend upon the general state of the patient’s health, because I shall have frequent occasion to refer to this subject in the succeeding parts of the work.

I feel

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I feel much gratified in finding, that, though a larger portion of experience has enabled me to add some new and striking facts to this edition, it has not shown me any thing that I ought to retract or materially to alter. This, indeed, must be the case in a book containing only facts, and opinions not incautiously deduced from them. Several of the papers contained in these volumes met with very general and strong objection, which I considered as the greatest compliment that could be paid to them. For if the views which I had taken of various practical subjects were different from those of others, and were ultimately found to be correct, the greater was the necessity for their publication.

SUR-

SURGICAL OBSERVATIONS.

ON THE CONSTITUTIONAL ORIGIN, AND TREATMENT OF LOCAL DISEASES.

N evil seems to me to have arisen from the artificial division of the healing art into the medical and surgical departments. This division has caused the attention of the physician and the surgeon to be too exclusively directed to those diseases which custom has arbitrarily allotted to their care. The effects of local disorders upon the constitution have, in consequence, been too little attended to ; and indeed I know of no book, to which I can refer a surgical student for a satisfactory account of those febrile and nervous affection s which local disease produces, except that of Mr. Hunter. # The reciprocal operation of constitutional disorders upon local diseases has obtained

* Treatise on the Blood, Inflammation, &c.

VOL. I. it still still less attention. To investigate more particularly some parts of these subjects, and to submit them to public notice, are the proposed objects of the present paper.

No part of the animal body can in general be very considerably disordered without occasioning a correspondent derangement in other parts of the system. Such disorder has been considered by Mr. Hunter as the result of universal sympathy. This consent of the whole constitution with its parts manifests itself, in particular instances, by a greater disturbance of the functions of some organs than of those of others ; and from this circumstance diseases have derived the appellations, by which they are commonly distinguished. If the actions of the sanguiferous system be principally disturbed, and the temperature of the body subject to unusual variations, the disease is termed fever : if the nervous system be chiefly affected, a state of vigilance or of delirium may be produced: and when the functions of the muscular system are more particularly disordered, convulsions and tetanus take place. Though the disorder of particular organs thus gives a character and denomination to the disease, it is sufficently evident, in the instances adduced, that the whole constitution is disturbed ; while certain parts are chiefly affected, perhaps from unknown circumstances relative to the nervous system, or from a predisposition to disorder existing in the affected parts. It seems to be ascertained, that persons of particular constitutions are predisposed to those febrile actions of the sanguiferous system, which constitute the inflammatory fever ; that there is a propensity to convulsions in children ; and to tetanus in the inhabitants of warm climates.

It may be a fit subject for enquiry, whether it be possible for particular organs to become affected otherwise, than through the medium of the nervous system in general. Though some instances of sympathy are strange, and perhaps inexplicable, there are strong reasons for believing that the inflammatory fever, the state of vigilance and delirium, convulsions and tetanus, which arise in consequence of injuries of the limbs, are

b 2 produced produced by irritation imparted to the brain, which, by a kind of reflected operation, occasions a greater disorder of some of the organs of the body than of others, and thus gives a character and denomination to the disease.*

* Mr. Hunter, who, with that patience and industry for which he was so remarkable, collected and examined all the facts which he had observed relative to the subject of sympathy, has divided it into continuous, contiguous, and remote. It is the remote sympathies, according to his division, of which I am now speaking.

The observations of Dr.Darwin on ocular spectra, and indeed the consideration of the nervous functions in general, render it highly probable that sensation is not produced merely by impulses made on the nerves, but by means of actions excited by such impulses, which actions are continued to the sensorium. Nervous actions, then, may take place without the usually exciting causes : such actions may be continued through the medium of the reticular communications of nerves, and thus physiologically we may explain the continuous and contiguous sympathies. Actions also productive of sympathetic sensations may be supposed to take place through the media of ganglia or plexuses. In remote sympathies, however, we must suppose the actions which originate in an injured or diseased part of the body to be continued to the sensorium, and there to excite the actions of other nerves, &c. For a more full account of Mr. Hunter’s opinions on these subjects, see the third lecture delivered in the Royal College of Surgeons, in London.

That

That the stomach and bowels are disordered bj injuries and diseases of parts of the body, has been remarked by various persons ; but the subject has never been extensively surveyed, nor viewed with that accuracy of observation, which its high importance merits. It has been observed that sprains of tendinous or ligamentous parts produce sudden sickness ; and Mr. Hunter has attributed that shivering which is consequent to accidents, and attendant on some diseases, to the state of the stomach. It is known that, in some local injuries from accident or operations, the stomach has appeared to be the part principally affected. But remarks on the affections thus induced in the digestive organs have been made only in a cursory manner ; and it is my intention to examine the subject more particularly. It also appears to me that the connection of local diseases with the state of the constitution in general is either not sufficiently understood, or not duly regarded, by the generality of practitioners ; and I likewise mean to claim their particular attention to this subject. I shall in the first place select a case

b 3 to

6 ON THK CONSTITUTIONAL ORIGIN,

to show how the stomach and bowels, or, to speak yet more extensively, the digestive organs, may be affected from local disorder.

Sudden and violent local Irritation will sometimes produce an equally sudden and vehement Disorder of the digestive Organs.

CASE I.

A healthy gentleman, about twenty-five years of age, was induced to submit to an operation for the return of an adherent omental hernia, rather in order to remove the inconvenience and apprehension which the disorder occasioned, than from any urgent necessity : for any increased exertion in walking, or riding, produced the descent of a portion of intestine behind the thickened omentum, and obliged him to stop, and replace it : and he frequently could not accomplish the reduction without considerable difficulty. The application of trusses had been quite ineffectual in obviating these alarming inconveniencies.

The

The patient’s diet on the day preceding the operation was scanty, and consisted of fluid substances. He took on the morning of the operation some Epsom salts and manna, which purgedhim twice, and seemed to have emptied his bowels. A portion of the omentum was cut off, and after two vessels had been tied, the remainder was returned. The operation was followed by general disorder of the system, manifested by a full and strong pulse, furred tongue, great anxiety, restlessness, and total want of sleep. The stomach was particularly affected, being distended, uneasy on compression, and rejecting every thing that was swallowed. He was bled largely in the evening, and took saline medicines, but could not be prevailed on to swallow any thing else, except some toast and water. The sickness had in some degree abated on the next day. A solution of sulphat of magnesia in mint- water was prescribed in small doses, given at regular intervals, in order to relieve the disorder and distension of the stomach, by procuring discharges from

b 4 the the bowels.* In the course of the day he took an ounce of the salts, which were not rejected by the stomach ; yet he could scarcely be prevailed upon to take any thing else. The tongue was still covered by a thick yellow fur ; the skin was hot and dry, and the pulse frequent. As there was no particular tenderness about the hypogastric region, he was not again bled. The second night passed without

* It is most probably the disorder of the brain first affects the stomach ; but the re- action of the latter affection is liable to increase and maintain the former-, by which it had itself been produced. The effects that result from the sympathy of the whole constitution with local disorder vary greatly both in nature and degree. Sometimes the brain is the part chiefly affected ; on these occasions the nervous energy appears to be much impaired ; and in some instances of this description, the patient gradually sinks, little fever or re-action of the constitution being observed ; in other instances, however, there is a low delirium, with a slight degree of febrile action ; and in others again, the delirium is more violent, and is accompanied with a proportional increase of fever, subsultus of the muscles, and convulsions. Sometimes other parts of the body or particular organs seem to be principally affected : indeed the variety of effects produced under the circumstances alluded to is such as to baffle description.

any any sleep. As the salts had produced no effect, the same medicine was ordered in an infusion of senna, with the addition of some of the tincture, which, by being given in very small doses, was retained. When, however, it seemed likely that no effect would result from this medicine, a grain of calomel was given at night, and repeated on the following morning. Still the loathing of food continued. The third night passed, like the former ones, without sleep, and in great anxiety. On the next morning, two pills, containing five grains of the pil. colocynth. and the same quantity of the pil. aloet. cum myrrha, were given every fourth hour. These procured no stool, nor produced any sensation which inclined the patient to believe that they would operate. Again he passed a sleepless night; but, towards the morning, he felt his bowels apparently filling, to use his own expression, and a profuse discharge ensued. A dozen copious, fetid, and black evacuations took place between five and ten o’clock, and he had several others in the course of the day; after which his appetite returned, his tongue

became became clean, and a sound and continued sleep succeeded.

That the chylopoietic organs were the parts chiefly affected in this case can scarcely be questioned. The sickness, the tenderness of the parts in the epigastric region, the aversion to food, and the state of the tongue, all indicate that the stomach was much disordered. The insusceptibility of the bowels to the action of medicines, which would ordinarily have produced discharges from them, and the profuse evacuations which subsequently relieved the patient, prove that these viscera participated in the affection. The black colour of the discharges shows, I think, that the secretion of the bile was not healthy, and that the liver was affected with the other chylopoietic viscera.

It may be supposed, that the injury done to the omentum might contribute to produce the disorder of these organs, rather than of others. We do not, however, find thatsuch effects commonlysucceed to similar

operations.

AND TREATMENT OP LOCAL DISEASES* 11 operations. The consequences in the present case were more severe than might have been expected, if it were not known, that an operation performed on a healthy patient is more apt to produce considerable disorder, than when performed on one whose constitution has previously sustained the irritation of a disease, for which the operation becomes necessary.

It is probable also that the restlessness and anxiety of the patient were aggravated, if not principally caused, by the state of the chylopoietic viscera ; since the relief which took place in those parts on the renewal of secretions into them, certainly removed the nervous and febrile symptoms. That the discharges were the effect of secretion is proved by the absence of alimentary matter in the bowels, in consequence of the action of the purgative administered on the morning of the operation, and the abstinence both before and after that period.*

I could

* Two instances are recorded in Mr. Pott’s works, of the operation for the reduction of an hernia being performed

I could relate numerous cases in support of the inferences, which I have drawn from the preceding history ; that local irritation acting on the nervous system may affect the digestive organs in a very serious manner, and thereby create great disorder of the who leconstitution, which is afterwards alleviated in proportion to the amendment that ensues in the state of those viscera. Such consequences of great local irritation must frequently occur to every one ; it is therefore unnecessary to adduce more instances to support the opinions here delivered.

formed where no strangulation existed. See Pott’s works, vol. iii. pp. 295. 299. edition of 1783.

The operation in the case just related was undertaken upon the authority of these cases, which were both successful. I performed a similar operation on a patient, whose life had been twice in imminent hazard from strangulation in a case of adherent epiplocele, in which a truss did not keep up the hernia, and the operation was followed by violent peritonitis, which could only be subdued by such copious and repeated venesection, as endangered the patient’s life. These two cases have made such an impression on my mind, that I should be very averse in future to undertake similar experiments.

With

With respect to the treatment of cases of this description, it may be right to add, that the primary object should be to produce secretion from the irritable organs. In the case which has been related, and in many others recorded in this volume, the effect of secretions occurring from the disordered organs in relieving their irritable state is very manifest. In many instances opium will not prevent continual efforts to vomit, yet when by sulphat of magnesia, or purgatives administered in the form of pills, and clysters, stools are procured, the vomiting ceases, the stomach retains both food and medicine, and general tranquillity of constitution is as suddenly restored.

CASE II.*

A gentleman fell with his leg between the bars of an iron grating, which served as

* This Case was printed in the first edition of this paper, but afterwards suppressed as superfluous. It is now reprinted, because it is a striking evidence of the inexplicable disturbance of the vital energies, which is often the result of various fatal occurrences, though their immediate effects do not seem at all adequate to produce such general disorder.

a window a window to a cellar. The part was much bruised, the skin grazed, and the tibia broken into three or four pieces at its upper extremity. The limb was put up in splints by a neighbouring surgeon, and the next day the patient requested to see me in consultation. I attended for a few days, but every thing went on so well, that I discontinued my regular visits, and only called occasionally, without seeing the limb. There was no inflammation ; the swelling which had been occasioned by the bruise had subsided, and where the skin had been grazed, two or three trivial ulcers had taken place, which obliged the surgeon to open the bandages and dress them daily. The patient’s health had been so good, that about the middle of the fourth week after the accident, he had some friends to dine with him in his room, and afterwards played at cards with them, and parted with them, in the evening, in high spirits. In the middle of the same night, the patient suddenly became delirious, and I was sent for to meet the other surgeon in consultation. The delirium was then so great, that the patient

knew knew not the persons in the room. On looking at the leg, with a view to inquire into the cause of this unexpected occurrence, it was found, that one of the ulcers of the skin on the outside of the limb, on which his position had produced some pressure, had become deep, and apparently penetrated the fascia, so as to communicate with the fractured bone, and thus had converted a simple into a compound fracture. To this event we could not but attribute the sudden irritation of the constitution, and the delirium. Opium was immediately given, which quieted this disturbance in a considerable degree ; so that on the next day the pulse was more tranquil, and there was no delirium. On the following day his stomach became affected ; he was sick, could take nothing by the mouth, had the hiccough, and his abdomen was distended like that of a person in tympanitis ; whilst the senses and intellect were not disordered as they had been. In this state he continued about twenty-four hours, when his sufferings were terminated by death. As

some some suspicions had arisen that the head or abdomen might have been hurt at the time of the accident, the body was inspected ; but no injury of these parts was discovered. Upon examining the leg, it was found that the external wound communicated with the fractured tibia, which was broke into several pieces ; some of the fractures, ascending in a perpendicular direction, communicated with the joint of the knee. In this case the disease was of too short duration for observations to be made respecting the secretions of the chylopoietic organs ; but it was evident that there was a complete atony of the stomach and intestines.

A slighter Degree of continued local Irritation mil 'produce a less violent Disorder of the digestive Organs.

If, then, vehement local irritation can produce a violent disturbance of the chylopoietic organs, it may be expected that a less degree of a similar cause will produce slighter

effects effects of the same nature. Indeed, the foregoing case was related not merely because it seemed worthy of record by itself, but chiefly to prepare the reader for the observations which are to follow.

This slighter degree of disorder occurs in the advanced stages of lumbar abscess, diseased joints, compound fractures, and all kinds of local disease, which impart considerable and continued irritation to the whole constitution. We also find a less important disease, as for instance, a fretful ulcer, keep up a disorder of the system in general, and of the digestive organs in particular, which subsides as the irritable state of the ulcer diminishes. But as practitioners in general may not perhaps have so attentively remarked these circumstances as to be familiarly acquainted with them, it may be useful to notice a very common occurrence, which cannot have escaped observation. I allude to the effects of the irritation of teething upon the health of children. The brain is sometimes so affected as to cause convulsions ; the digestive organs are almost con-

vol. i. c stantly stantly disordered. The appetite fails ; the tongue is furred ; the secretions of the liver are either suspended, diminished, or vitiated. The bowels are either purged or costive, and the faeces fetid. The faecal matter is often mixed with mucous and other secretions. There is also frequently a very troublesome cough. Such symptoms generally subside when the local irritation ceases, but sometimes the disorder of the digestive organs, thus excited, continues and disturbs the general health of the patient.

If local irritation be capable of disordering the bowels, it seems natural to conclude that it acts upon them through the medium of the brain. If also the brain and nervous system should be disordered, without any apparent local disease, similar derangements may be expected to take place in the functions of the digestive organs. In cases, where some morbific poison has been absorbed, producing effects similar to those of syphilis, we usually find the irritation of the constitution which ensues to be accompa-

19 nied nied with this slighter disorder of the chylopoietic organs -

Whenever, also, the nervous energy and general powers of the constitution have been weakened and disordered by any violent disease, as fever, small-pox, measles, hooping cough, &c. the digestive organs are frequently effected in consequence, and such affection becomes, as will afterwards be explained, the cause of many secondary diseases.

In persons, likewise, who have naturally a weak or irritable state of the nervous system, we find the digestive organs disordered in a similar manner. Improprieties in diet will also produce a similar state of irritation, weakness, and disorder of the functions of the digestive organs.

This slighter disorder of the chylopoietic organs is, in general, manifested by a diminution of the appetite and digestion, flatulence, and unnatural colour and fcetor of the excretions, which are generally de-

c 2 ficient ficient in quantity. The tongue is dry, whitish, or furred, particularly at the back part; this symptom is most apparent in the morning. The fur is greatest at the back part, and extends along the middle of the tongue tothetip, the edges remaining clean. As the disease advances, a tenderness is felt when the epigastric region is compressed, and the patient breathes more by the ribs, and less by the diaphragm than in the healthy state. The urine is frequently turbid.

In this general enumeration of the symptoms, several circumstances are omitted which occur occasionally, and which may, when the subject shall be better understood, denote peculiarities in the disease, and require corresponding peculiarities in the medical treatment. I shall here notice a few of them. The appetite is sometimes moderately good, when the digestion is imperfect; and the latter may not be defective, although the disease still exists. In some instances, indeed, the appetite is inordinate. Tenderness of the epigastric region on pressure, is not always an attendant, even in

i > advanced advanced stages of the disease. The bowels are alternately costive, andlax even to purging.* The urine is sometimes pale-coloured, and copious like that of hysterical patients.

Patients affected in the manner above described commonly declare they are in good health, except that they feel disturbed by their local complaints ; yet they are found, on enquiry, to have all the symptoms, which characterise a disordered state of the digestive organs. The mind is also frequently irritable and despondent ; anxiety and languor are expressed in the countenance. The pulse is frequent or feeble ; and slight exercise produces considerable perspiration and fatigue. The patients are sometimes restless at night, but when they sleep soundly they awaken unrefreshed, with lassitude,