Application of the physiological doctrine to surgery

Front matter

APPLICATION

OP THE

TO

Preface

OF THE TRANSLATOR.

The science of medicine has been much improved of late, by the labours of French physicians ; and it is to Broussais and his followers that we are principally indebted, for the reformation which has taken place both in Medicine and Surgery. The growing importance and increasing popularity of the New Doctrine, have caused many works involving its principles, to be translated into the English language ; but amongst them all, I have not yet seen one professedly treating of the application of the doctrine to Surgery. The subject is alluded to by some, and passed over in a cursory manner by others. M. Goupil, in his Exposition of the New Medical Doctrine, makes some few remarks in relation to it, and concludes by referring the reader to the present work of M. Begin. It is with a view, therefore, of offering something upon this important subject, to those of the profession who are unacquainted with the original tongue, that I have undertaken the translation of the following pages.

iv. PREFACE.

It is unnecessary for us to say who the author of this work is : M. Begin has been long and favourably known as one of the most zealous advocates of the New Medical Doctrine ; and his Traite de Therapeutique, which was translated some years since, was universally allowed to be the ablest production of the Physiological school.

On the merits and demerits of the New Medical Doctrine, enough has been said to preclude the necessity of my making any considerable comment here. That it contains errors, cannot be denied ; but that it is rich in benefits, must equally be admitted by every candid and intelligent physician. We may regard it as a new light emitting some of its luminous particles over the wide and extensive field that lies before us, dispelling some of the clouds and mists which have long hovered over it, exposing new paths, and pointing out new directions, to the wanderer after truth, and the impartial votary of science. It becomes us then, in relation to this as well as to every other doctrine, to select those truths which are consistent with our own reason and observation, and to reject those assertions which our experience does not sanction : in a word, doctrinam acri

I have endeavoured to give the reader a correct translation : whether I have succeeded or not, it remains for others to judge. Errors have occurred in the printing of the work which escaped

PREFACE. V.

my observation until it was too late to correct them : the most important of these, I have placed in the Errata ; the rest, the intelligent reader will quickly detect, and alter for himself,

Charleston, Feb. 1835.

Contents

Page.

Preface of the Translator, .... .

Preliminary Discourse, ... . . . . ix.

Chapter I. Local affections produced by acute surgical

lesions, . 27

" II. Local treatment of acute surgical diseases, 35

" III. Sympathetic phenomena determined by acute

surgical lesions, . . . . . 64

44 IV. Treatment of internal irritations which complicate surgical affections, ... 72 44 V* Nervous affections determined by acute surgical

44 VI. Local alterations determined by chronic surgical lesions, . . . . . .113

44 VII. Local treatment of chronic surgical diseases, 138 44 VIII. Sympathetic phenomena produced by external

chronic irritations, . . . . . 188

2 IX. Treatment of internal irritations which complicate chronic surgical diseases. . . . 205

ERRATA.

Page. Line. For. Read,

30 2 of cancers which.. cancers, which

" 13 effects effect

41 20 farfor farfrom

45 15 circulating circulatory

48 7 animal broths broths

50 19 theyare.... it is

" 21 them it

51 8 they produce it produces

52 1 ought to be necessarily ought necessarily to be

58 18 supply supplies

79 20 continued .continual

91 4 depend depends

96 17 24 The stupor stupor

97 6 17 23 the stupor , stupor

114 16 fistulas.. ....fistula?

127 1 Chirurgical nosography The Chirurgical nosography

149 15 is are

152 22 parches parch

180 5 have given give

9 it depends they depend

200 6 gives give

205 8 this that

PRELIMINARY DISCOURSE

The domain of medicine is, they say, too extensive to be cultivated entirely, by a single individual. This proposition is not entirely correct. It might have suited an age when all diseases had their particular theory; when the history of each of them was composed almost exclusively, of the more or less fantastical assemblage of hypotheses advanced by authors upon this subject ; finally, an age in which there did not exist in physiology and pathology, any general principle founded upon observation, and which could serve as an only and incontestable basis, to the history of the functions, as well as to that of diseases. Then, 2

X. PRELIMINARY DISCOURSE.

without doubt, the best organized head, the mind the most studious and most opinionated, aided by the longest life, could not have been able to embrace all the parts of the science of man; that is to say, to retain and classify those contradictory opinions, those abstract theories, those incoherent results of observations disfigured by the imaginations of those who collected them, of which but lately the greatest part of medicine was still composed.

These obstacles have almost entirely disappeared in our day. The field of science has been disembarrassed of the useless materials which encumbered it ; and its soil, exposed to view, and cultivated in a manner more rational, is at length covered with rich harvests. On the one hand, all the doctrines which observation does not sanction, are rejected, whatever may be the celebrity of their authors ; on the other hand, all the results which appear to be the exact expression of facts, are admitted, in spite of the opposition that may exist between

PRELIMINARY DISCOURSE. XI.

them and tl\e most accredited ancient theories. It is only by proceeding with this vigour and this independence, that we can arrive at the perfection of Physiology and Pathology.

Great advancements have been made to attain this end; and if new investigations are still necessary, we ought to hope that they will serve very soon to elevate medicine to that degree of certainty and regularity which distinguishes actually physics and chemistry. Already do the general principles established and universally adopted, permit us to have a glimpse of that happy epoch ; and as these principles are. actually in relation with the amount of the known facts, it is very probable that future discoveries will serve to confirm still more, their exactness.

These improvements are common to medicine and to surgery ; for both ought to found their basis on pathological physiology. To maintain that surgery consists in nothing more than the application of mechanical means to

XII. PRELIMINARY DISCOURSE.

the body of man, is to give it an incorrect definition ; and which, contradicted by the actual nature of things, could not be just, but in the ages when this science was cultivated by physicians, or when the performance of operations was abandoned to the hands of the ignorant and barbarous. This definition only serves to restrict the ideas of students who are destined to undergo a surgical course, and to make them believe that they can keep within the bounds of the list of operators. The surgeon has a task more important and more noble to fulfil. At the same time that he devotes himself especially to the performance of operations, he ought to make an especial object of study, the diseases which require the employment of those extreme resources of a conservative art. There exists, therefore, one part of pathology, which forms in some sort, the particular dominion of surgery.

But in adopting such a principle, it must not be forgotten, that the affections termed surgical?

PRELIMINARY DISCOURSE. Xlll.

are constantly complicated either with derangements in the rhythm and intensity of the organic movements, or the result more or less slow of modifications contributing to the exercise of these movements. The surgeon cannot forget without danger in practice, that at the same time that he remedies by operations the derangements of our parts, he acts upon sensible, irritable tissues disposed to become the seat of violent inflammation, and united to the principal viscera of the living economy, by sympathies more or less close. He ought to remember, moreover, that medicinal means properly administered, often render unnecessary the most serious operations, and are constantly necessary to facilitate and secure the success of these operations.

It is therefore indispensable, that the practitioner who makes surgery his principal occupation, be at the same time a skilful physician : he ought to know both the anatomical disposition of the diseased parts, and the laws which

Xiv. PRELIMINARY DISCOURSE.

preside over their functions and the manner in which the tissues are affected by the lesions which he remedies. Without this knowledge in some measure preliminary, how can he judge of the necessity of performing most operations ? If he is ignorant of the laws of the sympathies, how can he institute an internal and external methodical treatment % how can he prepare the patient to support the action of instruments, and prevent or combat the affections which that action frequently determines. The surgeon who would confine himself to manual operations, would be only an ignorant and rude workman ; knowing neither the disposition nor the properties of the matter upon which he acts, we would see him in his blind and undeviating attempts, commit at each step the most fatal errors.

The practitioners who cultivate surgery especially, could not evidently remain strangers to the improvements of medicine, without incessantly compromising the honor of the art, and

PRELIMINARY DISCOURSE. XV.

without exposing the afflicted to the most serious accidents. But it is incontestable, that it is only within a few years, that the physiological doctrine has given to medical studies and* practice a new impulse, and has rendered them eminently philosophic. The actions and sympathies of different organs better known ; the nature, the immediate effects and remote results of irritations, explained with exactness ; the theory of inflammations and of hemorrhages called passive, brought to light ; the etiology and the principal phenomena of scurvy, explained by an unexpected alteration in the composition of the nutritive materials ; the entire class of essential fevers effaced from the tables of nosology ;* finally, this grand principle, that all diseases consist in the lesion of one or more organs, established upon immoveable foundations : such are some of

* Among the works best written, and which are the most proper to place beyond doubt the true nature of ievers, we cannot too often cite the excellent Pyretologie Physiologique, recently published by M. Boisseau. This book is remarkable

XVI. PRELIMINARY DISCOURSE.

the ameliorations accruing to the history of diseases, by the new doctrine. The works of M. Broussais, and those of the physicians of the physiological school, have given to the science a new aspect : it appears that by their efforts, observation has been rendered more scrutinizing, experience more sure, and medical reasoning more luminous and more productive.

If any thing ought to be surprising in the midst of the general agitation of minds, it is, that surgery has participated scarcely any, in the recent improvements in pathological physiology and internal medicine. It suffices to open the most esteemed elementary works, those which have been published most recently upon the science, to be convinced of this truth. Their authors appear to have uudertaken the task of reviving the most antiquated opinions, of sustaining errors the most completely refuted,

for the talent which has presided over its composition, for a criticism of the ancient theories as luminous as just, and for the solidity of the proofs which it contains in favour of the soundest doctrines.

PRELIMINARY DISCOURSE. XV1J.

and of religiously preserving, even the most dangerous therapeutical principles. 1 need not cite any of those books; we can easily perceive the hypothetical doctrines, the humoral, mechanical, or Brunonian theories which they contain in each page.

A small number of isolated observations, relative to the treatment of certain acute or chronic inflammations of the external parts of the body, by leeches and topical emollients, constitutes almost all that we possess, relative to the application of the physiological doctrine to surgery. M. Gama, chief surgeon to the military hospital of instruction at Strasburg, has, however, composed upon this fruitful subject, a discourse too little known, but remarkable for profound and attentive observation, and for considerations as extensive as judicious. In fine, if I were permitted to mention myself here, I would claim the honor of having a long time since, and perhaps one of the first, applied the principles of the new doctrine, to the theory and 3

XV111. PRELIMINARY DISCOURSE.

treatment of surgical diseases.* But it remained to consider the lesions of the external parts of the body in their ensemble, to make obvious the general laws according to which the local and sympathetic phenomena which they determine, manifest themselves ; and finally, to establish the most rational basis of treatment which it is proper to oppose to them. All sound minds, convinced that physiological medicine ought to be as useful to surgery as to internal pathology, have waited impatiently for a work appropriated to the demonstration of this truth : it is this desire which I have endeavoured to satisfy in the following pages : happy, if in spite of my efforts, I have not remained too far below the object which I have wished to attain.

I am far from having embraced in this work, the whole dominion of surgery. There is, moreover, an important part of this science which

has no need of examination or revision, and which has not occupied my attention : it is that which has for its object, the study of the mechanism by which certain physical lesions are produced, and the descriptions of the practical proceedings and methods of operating. Here, all is after a certain manner, we may say, subject to calculation; the true principles, if not the limits of the art, are fixed; and the different systems of pathology, can have no influence, either upon their theory or their practice.

Whatever may be the extent, which I have been able to give to my labour, it was equally impossible for me to embrace, all the particular cases, in which could be made a useful application of physiological medicine to surgery : Thus, fractures of the scull; the disturbances, contusions, and separations of the brain and its membranes ; the solutions of continuity in the thoracic and abdominal viscera; the sanguineous, purulent, or serous effusions into the cavities of the pleura, or of the peritoneum:

XX. PRELIMINARY DISCOURSE.

the various lesions and abscesses of the liver f intestinal incarcerations; foreign bodies lodged in the digestive canal: these are some of the lesions, the methodical treatment of which, requires a thorough knowledge of the new medical doctrine.

Wishing then to Compose, not so much a treatise on surgery, as a sort of introduction to the study of that important branch of the healing art, and being obliged to confine myself to general rules on the theory and treatment of surgical lesions, and the affections which may complicate them, the plan which 1 have followed, although very proper to fulfil my views, may appear, perhaps, not sufficiently methodical; nevertheless, I could not adopt the classification of the diseases in physical, vital, and organic lesions; simple, it is true, but anti-physiologick. The greatest part of physical lesions, are, in effect, constantly followed, either immediately, or after a very short time, by derangements in the rhythm and force of the organic movements.

PRELIMINARY DISCOURSE, XXI.

It is for this reason, that wounds, fractures, and luxations, give rise always, to inflammations more or less lively, and ordinarily so intense, that it does not suffice merely to reunite or to replace the parts, but also, to prevent or to combat in an energetic manner, their irritation and its effects. The vital lesions, in their turn, determine, in nearly all subjects, alterations more or less profound, in the texture of the parts of which they are the seats ; alterations which constitute, notwithstanding what may be said, true organic lesions. Finally, the degeneracies of the living tissues, the development of new pathological tissues, are constantly and exclusively the result of vital lesions, which, after having formed those tissues, are enlarged, and preside over the numerous transformations which they are to undergo. In all cases of schirrus, cancer, melanose, etc. it is the irritation, or the vital lesion, which is the nearest and direct cause of the morbid organic production: the last is but an effect, a conse-

XX11. PRELIMINARY DISCOURSE.

quence of the other: it ought not to excite more than secondarily, the attention of the physiologist and the practitioner. We must then admit, ultimately, that vital lesions accompany, almost always, physical lesions; and that organic lesions are constantly produced, kept up, and modified, by the same vital lesions. What confidence can one give to a classification which enjoys in so high a degree, the privilege of separating arbitrarily, that, which in nature, is always one and indivisible ? I have then to follow another route. It appears to me agreeable to divide surgical diseases into two grand classes, the one to comprehend the acute lesions, and the other the chronic affections. Among the first, I arrange those diseases which appear rapidly, and which have a tendency to run their course in a very short time: such are wounds, fractures, contusions, and violent inflammations. It belongs less to me to examine those lesions, in relation to their etiology, and the mechanical operations which

PRELIMINARY DISCOURSE. XXlll.

they require, than with respect to the local arid general affections of which they are the source, the influence which they exert upon the principal viscera, and the medicinal remedies, internal or external, by which they may be counteracted. Such are the subjects which are treated of, in the first five chapters of the work. I have afterwards collected under the title of chronic surgical lesions, all those which succeeding to the former, or which developed by other causes, have a prolonged, and as it were, indefinite existence. I have endeavoured to trace back as far as the vital lesion which provokes and keeps up the most important affections of this kind, in order to establish on solid foundations, both the curative indications which they present, and the treatment the most proper to combat them. After having examined the sympathetic influence exercised by chronic surgical diseases, whether on the whole of the animal organization, or aspecially on different parts of the body, it has been easy for me to point out the

XXIV. PRELIMINARY DISCOURSE.

means that should be employed to remove these secondary affections, and show in what should consist, the preparation which the patients should undergo before performing great operations. But having spoken in the first chapter, of the effects of these operations themselves, and exposed the treatment which those operated upon should claim, the sufficiently extended circle of ideas which I proposed .to myself to develop, was finished.

I may be reproached, perhaps, for not having presented in this work, any considerations on surgical diseases which may be said to arise from the debility of certain tissues, or of the entire organization. I am far from denying the existence of this class of lesions ; but they do not appear to be quite as extended as certain persons think. Besides, other things of more importance demand our attention; and as there has been so deplorable an abuse made of stimulants, in surgery as well as in medicine, and the methods of strengthening the parts, or the

PRELIMINARY DISCOURSE. XXV.

whole of the animal economy, so much extended and perfected, that it is actually less necessary to show when these methods should be employed, than to point out the more numerous cases, in which they are injurious.

Finally, I have endeavoured in this work, to give physiological reasonings for a basis to surgical pathology and therapeutics. Certain persons, enemies to all researches, all reflection, I will say, to almost all theories founded upon an observation of the laws of the living organization, will accuse me, perhaps, of temerity. Nevertheless, there must be, at some future day, a wholesome physiology, that will enlighten and command all medical sciences; it is indispensable, that it should extend its empire over lesions, the theory and treatment of which, seem necessarily to have escaped its influence. Men who actually deny the importance of physiological medicine, the rapidity of its progress, and the happy results which it produces, resemble the

sophist who denied the reality of motion, even 4

XXVI. PRELIMINARY DISCOURSE.

when he saw his adversary walking before him : but neither their obstinacy, nor their efforts, will be able to hinder the medical revolution which is in operation, from receiving its entire development.

APPLICATION

QF THE

PHYSIOLOGICAL DOCTRINE.

TO SURGERY.

Chapter L

Local affections produced by acute surgical

lesions.

Inflammation supposes always the previous action of an irritating cause, upon the tissues which are its seat. This action determines the acceleration of the local organic movements, or irritation.

The afflux of the fluids, the engorgement of the capillary vessels, the passage of the red globules of blood into the canals which do not admit them during a normal state, and as a consequence, the swelling, heat, pain, and redness of the part; such are the results, more or less immediate, which irritation carries after it. If the acceleration of the organic movements be recent, the attracted fluids are not yet combined with the organic structure. By soaking the inflamed tissues in water, and washing them repeatedly after death, we may succeed very easily in getting rid of the whole of the red colouring matter, and restore them to their original size and appearance. But, if the local afflux has persisted for a longer time, the globules of blood combine in some sort with the parenchyma of the part effected; they appear to make an integral part of it, and we cannot detach them from it, by any mechanical process. Some persons have proposed to designate the first of these states, by the name of congestion or fluxion ; and not to give to any but the other, the title of inflammation. Without entirely rejecting this distinction, it would not be right to attach to it too much importance ; for, as Bichat has observed : the state of freedom or combination of the attracted fluids in the irritated parts, is only a secondary phenomenon, a consequence of irritation. This constitutes alone, that which is truly fundamental in inflammatory diseases : it alone determines the more intense sympathetic phenomena, independently of the material alterations of the effected organs.

Whenever an irritation developes itself in a part of the living body, we see a process commence, which can be terminated by a prompt healing, or by the destruction and death of the inflamed tissues or by the slow degeneration and complete disorganization of these same tissues. In the first case, the irritation being abortive at its birth, if 1 may use the expression, we observe a more or less rapid resolution of the inflammation ; or else, the phlogosis determining the secretion of a particular fluid, suppuration takes place. In the second, the parts not being able any longer to support the excess of action which their irritation imposed, cease to live, and become gangrenous. Lastly, in the third, the stimulation continuing itself in a slight degree, the nutrition of the organs which it usurped, is modified ; their parenchyma looses its physical properties ; its aspect is changed; and we see developed, masses or thin plates of fibrous, cartilaginous, and scirrhous tissues; and finally, of cancers which extend their ravages very far. The most simple acute irritation, that which aggravates a wound otherwise slight, may determine each of the phenomena which I have just enumerated.

The consideration of the different shades of alteration which the inflammed parts may present, merits, nevertheless, to fix the attention of the practitioner: it permits him frequently to discover, by a simple inspection of the organs, the violence and duration of the phlegmasia which effects them. The skilful and experienced observer, by examining with attention the traces which complicated diseases leave after them on dead bodies, can distinguish the parts which have been the seat of recent and sympathetic phlegmasise, from those on which irritation first made its invasion.

These general principles being admitted, we will examine the influence which they ought to exercise, over both surgical theory and practice.

All bodies capable of wounding our organs, may act as very powerful causes of irritation. When a part has been violently contused, its tissue separated and has experienced a rough and sudden displacement, we very soon observe the organic movements of the part become more violent, and the fluids penetrate its tissue in a greater quantity than in the normal state. An inflammatory swelling proportionate to the susceptibility of the individual, and the degree of local sensibility, as well as the more or less vascular texture of the parts, appears in some cases, and extends to some distance. The irritated tissues then acquire new properties : they are more red, and more compact; their functions cannot be exercised but with great difficulty; and many others of these, such as the cellular tissue and serous membranes, become inextensible and easy to tear, whether we wish to stretch them out, or tie them by means of ligatures. This last disposition, we may remark en passant, is the cause of the little success which follows the tying of arteries at the points where the cellular coat of these vessels is already inflamed. In such cases, we observe the cellular tissue to be cut under the threads; and as the middle coat of the artery is inevitably likewise cut, the internal coat, which alone remains un-

32 PHYSIOLOGICAL DOCTRUNE,

injured, being too feeble to resist the force of the blood, it breaks, and haemorrhage takes place.*

Irritation, and the inflammatory action which it produces, are, when they become too considerable, almost the exclusive causes of all the danger to which the patient is exposed, by those surgical lesions, of which death is not the immediate and mechanical result. After wounds of the brain, the lungs, and the abdominal viscera, if the person does not perish at the instant when he receives the wound, the period when the inflammation of the parts injured by the wounding body develops itself, is that, when life will be most strongly menaced. If no violent inflammation manifests itself after lesions of the external parts of the body, we will never observe either those acute fevers which cause the wounded very often to succumb, or those enormous swellings, in which the termination most ordinarily consists, either in the formation of large and multiplied abscesses, or in inexhaustible suppurations, or finally, in those

intense gangrenes which allow of na other resource than the amputation of the limbs.

Inflammation is, nevertheless, an action of the living parts, without which, none of the wounds inflicted upon organized beings can be cured. Under this relation, it is the most powerful agent which nature employs to remedy the lesions of the organization. But for it to be salutary, this inflammation should be confined within just bounds, and consist only in that degree of excitation which is indispensable for the displacement of disorganized parts, and the formation of cicatrices.

The human body, in the case which we now consider, is not susceptible of contracting several kinds of inflammations, some of which might be adhesive, the others suppurative, or ulcerative, etc. We observe in nature, only different degrees of intensity, in inflammatory actions; degrees which produce varied results, by reason either of the disposition of the affected parts, or the more or less considerable quantities, or different qualities of the fluids which penetrate them. 5

Not only does irritation and inflammation of the living tissues succeed constantly to lesions produced by external bodies, but these affections are the inevitable result of most of the operations of surgery. Make an opening in the parieties of the chest, penetrate into the bladder to take out a foreign body, extirpate a cancerous tumour; finally, cut off a member entirely; you will always observe an irritation develop itself in the parts which the instrument has divided, and often extend itself, by continuity of tissue, or by sympathy, to organs quite remote; and as after accidental wounds, if the patient does not sink immediately, either from pain, or loss of blood, the period of the development of inflammation, will be that when life will run the greatest risk. The surgeon can never forget this important observation without danger: it ought to serve as the basis of his practice.

Chapter II. Local treatment of acute surgical diseases*

It results from the preceding considerations, that in all cases, either of external injuries, or surgical operations, the most formidable affection which the practitioner has to contend with, is the local inflammation which has to develop itself. It is not necessary for us, notwithstanding, to endeavour to hinder entirely, the manifestation of inflammatory action. This end cannot be attained ; nature herself having an irresistible tendency to produce an afflux of the fluids to the stimulated parts. Besides, even when such an indication could be fulfilled it would be hardly right to undertake it, as it is only by means of an indispensable inflammation that the cure is effected. Neither should we, in the treatment of wounds, bruises, and other affections of the same kind, endeavour to produce the development of an adhesive or resolutive inflammation, at the same time that we use our efforts to repress suppurative or gangrenous inflammations. To adopt a similar language, it would be to enter anew into the domain of hypothesis or useless abstractions : it would be to substitute methaphorical and inexact expressions, for such as are always simple on account of their truth. Under the circumstances which we are placed, the practitioner ought to confine himself exclusively, to moderating the inflammatory action which is about to develop itself in the wounded parts, and to keep it in those bounds, where it is advantageous without the power of becoming hurtfuL