his paper on injuries of the head.
"utiliumque sagax rerum."
?
hor.
in estimating the practical penetration and clear judgment of abernethy, it was almost necessary to see him placed by the side of other men.
his mind was so quick at perceiving the difficulties which lay around any subject, that it appeared to radiate on the most difficult, a luminosity that made it comparatively easy, by at least putting that which, to ordinary minds, might have been a confused puzzle, into the shape of an easy, definite, and intelligible proposition.
it was immaterial whether the difficulties were such as could be overcome, or whether they were in part insurmountable; both were clearly placed before you; and whilst the work of the quickest mind was facilitated, the slowest had the great assistance of seeing clearly what it had to do.
all this was done by abernethy in a manner so little suggestive of effort, that, like his lecturing, it was so apparently easy, that one wondered how it happened that nobody could ever do it so well.
but when we saw him placed in juxtaposition with other men, these peculiarities, which, from the easy manner in which they were exhibited, we had perhaps estimated but lightly, were thrown into high relief, and by contrast showed the superiority of his powers.
the second series of essays he had dedicated to his old87 master, sir charles blicke. the third, the subject of our present consideration, he inscribed to his early instructor in anatomy, sir w. blizard. the dedication is straightforward and grateful.
the first paper of the series is interesting in two points of view. first, it was an important improvement in the management of a difficult form of a very serious class of accidents—"injuries of the head;" and secondly, it derives a peculiar interest from the parallelism it suggests between abernethy and one of the most distinguished surgeons of france, the celebrated pierre joseph desault—a parallelism honourable to both, yet remarkably instructive as to the superior discriminative powers of abernethy. desault's pupil, bichat, himself one of the most accomplished anatomists of his time, has left an eloquent eulogium on desault, which, although somewhat florid, is by no means above his merits. he says he was the father of surgical anatomy in france; and certainly few men evinced more sagacity, in that immediate application of a fact to practical purposes which constitutes art, than desault.
bichat, in his glowing analysis of desault's character, amongst other things in relation to his study of the profession, observes of him that "un esprit profond et réfléchi, ardent à entreprendre, opiniatre à continuer, le disposa de bonne heure à surmonter des dégo?ts qui précédent, et les difficultés qui accompagnent son étude. a cet age où l'ame encore fermée à la réflexion semble ne s'ouvrir qu'au plaisir, apprendre fut son premier besoin—savoir sa première jouissance—devancer les autres sa première passion23."
a quick and clear perception, for the most part untrammelled by preconceived opinions, led desault to a vivid appreciation of the immediate results of surgical proceedings; and as these were definite, successful, doubtful, or abortive, he either persevered with a characteristic tenacity of purpose, or at once and for ever abandoned them. he was remarkably happy in his selection and appreciation of the mechanical parts of surgery; and his quick88 perception disclosed to him several useful points in practice which depend on the more important truths of medical surgery.
now almost all this, as applied to the active portion of abernethy's life, is equally true of both. but desault was by no means so deep or so original a thinker as abernethy. like abernethy, he was clear and penetrative; but he did not see nearly so far, nor were his views nearly as comprehensive. desault was quick at detecting an error in practice, and in sensibly rejecting it. abernethy would unfold it, examine it, and, by his talents, convert the very defect into usefulness. desault had by no means, in the same degree, that power of reflection, that suggestive faculty, which, in endeavouring to interpret the meaning of phenomena, can point out the true question which it is desired to ask of nature, as well as the mode of inquiry.
all this, and much more, was strikingly developed in abernethy. the paper before us involves a subject which had engaged the attention both of abernethy and desault. they had met with the same difficulty; and the practical solution of it which each obtained, though somewhat different, was extremely characteristic. we will try to make this intelligible. in severe injuries in which the cranium is broken, it frequently happens that a portion of bone is so displaced that it presses on the brain. the consequence of this, in many cases, is a train of symptoms sufficiently alarming in themselves, but the actual cause of which many circumstances sometimes concur to complicate or obscure.
the same forces which produce the accident not unfrequently involve a violent shock to the whole body. sometimes fracture or other injury of other parts. sometimes the patient is deeply intoxicated. then, again, patients are presented to the surgeon, in different cases, at extremely different intervals after the reception of the injury; so that a case may wear a very different aspect according to period or the phase at which it is first brought under his observation.
these and many other circumstances give rise to various modifications of the symptoms, and, under some complications, constitute a class of cases which yield to none in importance or difficulty. there is something in the idea of a piece of bone pressing89 on the brain, which instinctively suggests the expediency of raising it to the natural level. this is, in fact, the object of what is called "trepanning;" or, as we generally term it, "trephining."
the operation is very simple; it consists in carefully perforating the cranium, and then, by means of an instrument adapted for that purpose, restoring the piece of bone, which has been depressed, to its natural level. in many instances, the proceeding was very successful; but in many others, the cases terminated unfavourably. from what has been already hinted, it is clear that, in many injuries of the head, this trephining must have been unnecessary; in others, inapplicable; and in both (as adding to the injury), mischievous. still, surgeons went on as before; so that, in a large class of injuries of the head, there was (if the bone was depressed) an almost uniform recourse to the trephine.
again, in cases where it did not immediately appear that the bone was depressed, too often very unnecessary explorative operations were undertaken to determine that circumstance. in short, there was too much of analogy between the matter-of-course adoption of the trephine in severe injuries of the cranium, and that which we have noticed in regard to bleeding in more ordinary accidents.
for correcting the abuse of this very serious operation, we are under great obligations to abernethy and desault; and we couple these illustrious names together on this occasion, because, although the amount of our obligation to abernethy is much the greater, we would not willingly omit the justice due to desault.
desault may have been said to have given the first blow, which so often determines the ultimate fate of a mischievous conventionalism—that blow which compels the consideration of its claims on our common sense.
desault had become extremely disgusted with the results of the operation of the trephine in his hands at the h?tel dieu; and, on consideration, although, as it would seem from bichat's edition of his works, he did not in theory absolutely ignore the occasional propriety of the operation, he practically for ever abandoned it; thus at once cutting the knot he felt it difficult or90 impracticable to unravel. as this was many years before his death, the principal argument on which he supported the relinquishment of the operation was simply that his success in the treatment of injuries of the head had been much greater since he had altogether laid it aside.
this is eminently characteristic of what people call "a practical man;" but, after all, it is not very sound reasoning. now, here it was that the discriminative excellence of abernethy began to tell.
in the first place, he observed that the raising of the bone could only be necessary where it produced symptoms. he also observed that experience had recorded certain cases in which, notwithstanding that the bone had been depressed, the patients had recovered without any operation. then again he thought it not improbable that, where the depression was slight, even though some symptoms might at first arise, yet, if we were not too precipitate, we might find that they would again subside, and thus so serious an operation be rendered unnecessary. these and similar reasonings led him to recommend a more cautious practice, and to refrain from trephining, even where the bone was depressed, except on conditions which referred to the general effects of pressure on the brain, rather than to the abstract fact of depression of the bone.
he did not stop here; but having thus placed restrictions on the use of the trephine, where it had been too indiscriminately employed, he then describes the practice which is to be pursued where the pressure is produced from effusion on the brain.
although, in laying down the rules to be observed in such cases, there is much of painful uncertainty as to the existence of effused blood, the site it may occupy, and other circumstances of embarrassment,—still the rules he proposes in relation to the avoidance of large vessels, the condition of the bone as indicative of the actual state of the parts beneath it, &c. are all clearly and beautifully stated, as deducible from the anatomical and vascular relations of the parts. the result of all this discrimination is, that the trephine is seldom employed, whilst the treatment of the various injuries of the head is much more successfully conducted.
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he next proceeds to consider the distinction between those cases in which the brain has been shaken merely (concussion), and those where it has been subjected to mechanical pressure. there are two points in this part of the paper of great interest to the practical surgeon: the one in which he treats of the distinction of the two cases; the other, in which he marshals the discordant practices of different surgeons in cases of concussion, and defines the proper phase of the case in which we may make them respectively applicable. when, for example, we may by warmth maintain, or even by cautious stimulation excite, the depressed powers; or, by judicious abstinence from either, avoid provoking too violent reaction; and, lastly, how we should combat the latter, if it unfortunately supervene.
his remarks on the assistance to be derived from the consideration of the phenomena of apoplexy, his reference to the cases which had occurred in the practice of other surgeons, and the observations he makes on the lamentable omission of facts in the record of cases, are all worthy of profound attention. equally excellent is the ingenuity with which he attempts the distinction between the cases of concussion, and compression, of the brain. his endeavour to discriminate the cases in which the effusion, or inflammatory action, respectively, affect one or other membrane, is also extremely sagacious and characteristic. whether we consider all or any of these features in the paper before us; or, lastly, that triumph of science and humanity with which he has so defined the limits of a dangerous operation, as to have achieved a comparative abandonment of it; we think most surgeons will be inclined to regard this essay as one of his happiest contributions to the improvement of practical science.
in 1804, he added some cases in illustration of the views unfolded in this paper; and one case which appeared to be exceptional, with what he considered to be its appropriate explanation. he also gives an interesting case of a suicide, in whom he had tied the carotid artery, and in whom the operation was followed by an inflammatory state of the brain. here, again, his quick perception suggested to him the significant idea that similar conditions of brain might result from different and even opposite states92 of the circulation—a conclusion now, i believe, well established; one of great practical importance; and one for which, so far as i know, we are greatly indebted to the observations of dr. marshall hall on blood-letting. in this case, abernethy eulogizes the plan recommended by desault, of feeding a patient by a tube introduced through the left nostril. in concluding this remarkable paper, which shows how much a great mind may extract from common subjects—
"tantum de medio sumptis accedit honoris"—
we quote one remark, which impresses the importance of a requisition, the essential basis of all scientific inquiries—namely, a careful collection of facts.
"in proportion as we advance in knowledge," says mr. abernethy, "we are led to record many circumstances in the progress of the disorder which had before passed without notice, but which, if known and duly attended to, would clearly point out to us the nature and remedy of the complaint. hence the records of former cases are of much less value, as the symptoms about which we are now anxious to inquire, have in them been entirely overlooked."
