his remarks on tumours.
"cogitatio in vero exquirendo maxime versatur. appetitus impellit ad agendum."—cicero.
"the intellect engages us in the pursuit of truth. the passions impel us to action."
in our brief sketches of abernethy's works, we are quite as desirous of showing why he did not do more, as we are of setting down faithfully our many undoubted obligations to him. this, indeed, is the best mode of giving an onward impulse to those approaches towards a definite science which (john hunter excepted) he was the first to secure. if we would increase the usefulness of those beautiful principles which he has left us, we can hardly do better than endeavour to point out any error or deficiency in the investigation of any subjects to which such principles may be applicable. his work on "tumours" contains much that is interesting in regard to the peculiar character of his mind, and his aptitude for simplification. he does not undertake a thorough investigation of the subject. his object seems to have been to place in an intelligible order, to chronicle and mark, that which was really known; to pack together, as it were, that which was clear and positive, in a form convenient for consideration; to remove that disorder and obscurity which seem to hang about the threshold of all inquiries, and substitute so much of arrangement and perspicuity as might invite, and perhaps facilitate, further investigation.
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he states the more important circumstances which he had observed, and conducts his classification of the so-called "tumours" on a basis as scientific as it could be on an imperfect induction of facts. he did this in a way eminently characteristic of his quick perception, in seizing those properties on which a nomenclature should be based, and in marking those distinctions which, in a practical science, must always be regarded as of the greatest value. he founded his nomenclature chiefly on certain resemblances, observed in these diseases, to well-known structures of the body.
the simplicity of this plan, so long as the resemblance is obvious, is just that which constitutes excellence in nomenclature. to take an example, amongst others, he says there is a tumour the structure of which resembles the pancreas, or sweetbread as it is popularly called, and to this tumour he gives the name of pancreatic. now every one knows a sweetbread, and the name implies no opinion whatever as to its nature; it simply declares a fact. whatever we may ultimately discover with regard to tumours, a name of this kind, though it may possibly be exchanged for one more significant of the nature of the disease, will still leave us nothing to unlearn; for the tumour in question will always have that resemblance from which mr. abernethy named it; and if we should find (as indeed we do find), in course of time, that diseases undergo alterations of type, the rarity of a tumour resembling the sweetbread would record that circumstance.
had he examined them by the microscope, and selected the appearances so elicited as grounds for his classification, it would have been much less useful. in the first place, comparatively few persons would have had the opportunity or taken the pains to observe; and secondly, we should have had the inconveniences resulting from that variety which we generally find in the reports of microscopic researches. there is just now a great disposition for microscopic inquiry, perhaps somewhat too much; but no channel should be neglected, if it be not too exclusively relied on. abernethy amused himself at one period in examining ultimate structure by the microscope; but he seems to have had but a very measured reliance on this mode of investigation.
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judicious nomenclature is of immense importance in the framework of science, and a want of care in this has probably done as much as anything to impede the course of rational investigation. there is nothing, perhaps, in the whole range of science more to be lamented than many—indeed, i might say all—parts of medical nomenclature. if our ignorance prevents us from giving a name to a thing which is descriptive of its nature, we might easily avoid applying such as are calculated to mislead. we can imagine the confusion which would result from a druggist labelling a bottle of water, "poison;" and a vessel containing poison, "water;" yet we doubt whether he would more imperfectly express the true relations of these fluids, than the terms "fever" and "inflammation" do the real nature of the conditions which they are employed to designate.
abernethy's arrangement of tumours not only illustrates his disposition to seize on the more salient points of a subject, but also his inclination to seek for the essential relations of (so-called local) disease in the general condition of the body. he consistently, therefore, mentions them in an order founded on such relations. he places those first which he had found least dangerous in their nature, least destructive in their effects, and which appeared to him to have been attended by the least disturbance to the general economy. in like manner he placed those which had manifested more malignant or dangerous characters, in the order of their severity; inferring their characters respectively from the disturbance of the constitution, the resistance of the disease to treatment, and the variety of structures destroyed in its progress.
between these two extremes, he placed, as the step of transition, that tumour which he had observed to partake most strongly of intermediate characters. but, besides the desire to throw some light on the subject of tumours generally, he had another special object in view. few diseases exemplify the absence of scientific research more than tumours. in regard to most of these morbid depositions, it may be remarked that, even now, whenever a patient with one of these so-called tumours applies for advice, the practicability of removal is too often the only thing thought of;109 and it must be obvious to common sense that the mere cutting away of a deposition of this kind (however proper under some peculiar circumstances), can hardly ever exert any influence on the causes of its production. indeed the manner in which these diseases are continually removed, without any previous inquiry that is really worthy of the name, is amongst the many grounds on which we found the opinion expressed in the sequel on the present state of medical surgery, as contrasted with that in which it was left by abernethy. now, while the gravity of the subject rendered the consideration of all tumours important, there was one which in an especial manner had eluded all efforts to expose its nature and dependencies—this was the justly-dreaded cancer. in regard to this, mr. abernethy hoped that further information might be obtained, by investigating other tumours more closely, and thus bringing, as he expresses it, collateral knowledge to bear on it, "like light shining from various places to illustrate the object of our researches."
here was a suggestion in the true spirit of philosophical inquiry; whilst, in taking so simple a basis for the names of tumours, and then associating them in arrangement with their respective constitutional tendencies, he adopted the best mode of recording in a general sense their more important relations. but the fault lay in the suppressed premise that the relations of the so-called tumours were comprehended by a division which is not founded in nature. nothing indeed can be more artificial than that division of diseases to which surgeons usually restrict the term tumour; a defect which besets all medical inquiries. the old division, in which all sorts of diseases were jumbled together under the general name of tumours, defective as it might be, was much more auspicious, had it ever been made the object of a really philosophical inquiry; because the very diversity of the phenomena they presented would, by the ordinary process of common sense or inductive reasoning, have only served to bring out their common characters—the most important first step in all investigations of this nature.
had mr. abernethy extended that collateral view which he justly insists on, to all sorts of new depositions, instead of confining110 it to the so-called "tumours," he would have detected how artificial was the division, and taken it at its just value; he would have found that he had excluded circumstances which not only led to a much more intimate knowledge of the relations on which those so-called tumours depend, but which confer a power of demonstrating easily, and in a more particular manner, to the most ignorant or prejudiced, those relations to a disordered state of the body, of which, without such assistance, it required a mind no less penetrative and suggestive than abernethy's to give even a general enunciation. this defect essentially consisted in the vice we have before alluded to, and is nothing else but a violation of one of the rules most insisted on by lord bacon28.
it proceeds, perhaps, from the habit of looking at subjects through a medium too exclusively anatomical, and by which even mr. hunter was sometimes, though exceptionally, hampered. popularly, it was deducing conclusions from only a portion of the facts of the subject; but if abernethy did not get the whole of the facts, and therefore missed some portion of the conclusions to be drawn from them, he at least avoided the error of inferring anything positive which the facts did not warrant. we hope, however, that the paper has been valuable, in enabling some of us to arrive at further views, which serve to confirm the truth and extend the application of those entertained by abernethy.
now, to put the whole thing popularly, and to direct the public view to the common sense of the matter, it is obvious that if we want to know the real nature of any growth whatever—say a tumour, a plant, or an animal—we cannot do this by any examination of its structure alone. if we desire to know its nature, we must also examine its habits, food, climate, and the various influences to which it is subjected. if, indeed, this were once done, then it is very possible, on again seeing the structure merely, we might recognize its real relations, although we might still be glad to have any well-known substance to which we could compare it, if only to record its identity. this is right enough, thus111 to obtain the general knowledge before we assume the particular. again, suppose i had some ground growing all manner of plants, and twenty different sorts of fungi, what should i get by merely examining the fibres of one or the other?
but i should easily discover that some plants grew best in one soil, some in another, some with more moisture, some with less; whilst the very circumstances of soil, moisture, and so on, which were essential to some, might be enfeebling or destructive to others. no one will for a moment doubt that the kind of nutrition was of great importance in all, and this would necessarily lead me to infer that, "if i desired to get such a fungus, i must have more moisture, less air, less heat or light, or another soil," and so on.
in a plant, you must also look to the roots and other parts of the organism. now this is exactly what should be done in regard to tumours; and for no reason more cogent than that the great beauty and beneficent effects of mr. abernethy's views may become practically useful; for in the same manner that we would desire to influence the plant or the fungus through the sources whence it derives its nourishment, as air, water, various ingredients in the earth, and so on; so the only channels by which we can effect any influence, are those organs by which these matters are ultimately changed into the structures we wish to maintain, or we desire to get rid of, as the case may be. now, although the number and relations of these organs may render the investigation more difficult in one case than in another, as they become more multiplied, or as the animal or vegetable is more or less simple or complicated in structure; yet, whether we take our example from man, or any other animal—or, in fact, any organized being of the countless modifications we find in nature—the instrumentality through which the vital power acts is neither more nor less than the assimilating organs.
if we have been too professional in this discussion, we plead, as an apology, that in no one point in the whole range of surgical practice would unnecessary suffering be avoided more frequently than on the subject before us; provided only that what is clear and positive, as distinguished from what is conventional and erroneous, were once popularly familiar; for, amongst other evils,112 most of the operations in this department of surgery are not only superfluous—to use no stronger term—but they practically interfere more than any one thing whatever with the progress of the scientific investigation of the nature of these maladies.
the removal of them by operation is too commonly undertaken, not only under circumstances which, as abernethy said, "add cruelty to calamity," but for reasons which logically forbid such a proceeding; and although there are conditions which call for such interference, yet those under which it is usually instituted help only to obscure the real relations of the disease, and to throw the shadowy veil of an irrational empiricism over the operations of nature.
those who recollect the remarkable results which abernethy sometimes obtained in regard to this intractable and often formidable class of diseases, will, i think, be disposed to agree in thinking that few maladies are more open to improved investigation, or promise a more encouraging prospect of enlarging the boundaries of philosophical medicine.
section.
his paper on a curious circumstance sometimes
following injury to the lungs.
fractured ribs are common accidents, and illustrate very beautifully those conservative principles in animal bodies which give such interest to the study of their economy.
when first we consider that the ribs form the greater part of that box in which the lungs and heart are enclosed, and by which they are protected, we are disposed to regard a fracture of one or more ribs as a very serious affair.
nevertheless, these accidents generally do extremely well. in the first place, the gristles, or cartilages as they are called, by which the ribs are attached to the sternum in front, give, in conjunction113 with the spine behind, considerable elasticity to the whole structure of the chest. most injuries have therefore to overcome this elasticity, before anything gives way; and when the rib has done so, and is fractured, the resiliency of the cartilage or gristle to which it is attached tends to restore it to its place, or to set it, as we phrase it.
another very curious thing in accidents is the instantaneity with which muscles which are ordinarily under the dominion of the will, become reluctant to obey it, or altogether repudiate its authority. in all fractures, of course, the most material thing is absolute repose; and there is very little chance of a man moving his rib when it is broken. he instinctively begins to expand his chest, for the admission of the necessary air, by other muscles, usually to the exclusion of those which are attached to the broken bone.
the lung, which may be considered as a series of tubes, some conveying blood, and others air, is often wounded; but the blood immediately stops the leak, from its tendency to coagulate when out of the vessels; and no harm ensues. occasionally, however, a circumstance occurs, which, until it is understood, appears curious and alarming. either from the extent, the scratching of the surface, or some other peculiarity in the wound of the lung, the air escapes from it, and the patient is as it were blown up, as to the chest, neck, and face, by the air impelled from the lung beneath the skin into the connecting tissue, exactly in the same manner as the butcher does when he is preparing veal. this blowing-up is called, from the greek word for it, emphysema; and it was on this feature in these accidents that mr. abernethy wrote a short paper.
there is not much which is absolutely new in it. it is chiefly remarkable for the clear manner in which it places before us what is required, as distinguished from what is officious and unnecessary, and, in fact, reduces the treatment to that of ordinary cases, with one clearly defined modification.
he shows his familiarity with pneumatics, so far as they are touched by the case, just as he does his knowledge of chemistry elsewhere. the exceptional cases, in which the air is confined in114 the chest, the mode of procuring it an exit by operation, and the condition regulating this proceeding, are very simply and clearly laid down.
the paper also contains remarks on the collapse of the lungs when the chest is opened, and on certain exceptions which have been observed, which, from their general interest and suggestive character, will well repay an attentive perusal.
he next offers a few remarks on those mothers' marks, as they are popularly called, and which are technically styled n?vi. they are generally little more than clusters of enlarged blood-vessels, and are usually removed by excision or other operative proceedings. as the essential character of these marks is increased action and size of vessels, mr. abernethy thought that, if well-regulated pressure were made on them so as to impede the flow of blood into them, and this were conjoined with cold (which represses vascular action), many of them might be got rid of in this manner. he found his idea realized, and published three cases of its success. the value of these suggestions consists, first, in the opposition they offer, pro tanto, to that absurd tendency there is to remove everything like a tumour; and the impediment thence arising to any searching inquiry into the causes on which they depend.
but there is another inconvenience which occasionally renders the excision of these n?vi very inadvisable. it sometimes happens that they are so situated that they cannot be removed, without making the disfigurement greater, or from some other still more serious objection; as, for example, when small ones occur in the face, or when they are placed near the eye. under such circumstances, the contraction consequent on a wound of any extent is a serious inconvenience; in some of these cases, the adoption of mr. abernethy's plan allows us to dispense with the operation by excision, as i have myself experienced. as it illustrates the advantage of the plan in a case where it was particularly applicable, i will briefly refer to one example. a young lady had one of these marks at the root of the nose, where, from the position, as well as from the contiguity of the eyes, any dragging from the contraction of a scar, would have been particularly115 undesirable. she was brought from the country to have it removed; but, on representing the objections to that course, it was agreed to try mr. abernethy's plan, which was completely successful.
at this period, mr. abernethy published sundry other interesting papers, showing, in his observations of all that was passing around him, that his views were not less circumspect and comprehensive than they were clear. his "surgical cases" are all excellent; and if they do not contain so full an account (the great vice of medical records) of all the circumstances which preceded them, as are sufficient to furnish future investigators with the elements of accurate generalization, they are remarkably valuable for the qualities of clearness and candour.
we may have an opportunity of briefly alluding to some of these papers in our summary; but they are hardly practicable subjects for popular analysis, although they form some of the most valuable contributions to the practical literature of the profession. they show also that he was as penetrative and efficient in regard to the operative department of practice, as he was in those higher and more extended views, which, in enlarging the science of surgery, has tended to diminish, of course, the number of operations.
about the year 1785, john hunter had invented his celebrated improvement in the treatment of a disease of the arteries called "aneurism." it was a very simple deduction from observations on the state of the arteries; and although it was one of those inquiries which had been made the subject of experiments on living animals, it was one on which not the smallest light had been thrown by such investigations.
mr. hunter had found that, in addition to many other serious objections to an operation which had been usually performed for the relief of this disease—which consists either of a giving way of a portion, or a general enlargement, of a vessel (for it is sometimes one, sometimes the other)—a great cause of failure had been, that the ligature which was placed round the artery was too near the disease, and, in fact, involved a portion of the tube which was unsound. he accordingly proposed116 tying the artery a little farther off, and thus substituted, for an operation which was extremely severe, very hazardous, and too commonly fatal, a comparatively short and simple proceeding, which, under moderately favourable auspices, is almost uniformly successful.
as with many other discoveries, accident and similarity of views had suggested similar proceedings to others, so that continental surgeons were disposed to dispute the merit of the discovery in favour of guillemeau, guattani, anel, desault, &c., as their views favoured one or other; but there can be no doubt that for the first clear exposition of the principles of the operation, as well as of the objects it was designed to accomplish, we are indebted to john hunter.
john hunter's operation applied to the main artery supplying the lower extremity, and surgeons have since extended the proceeding to many other arteries. the first extension of it, however, occurred to mr. abernethy, who, about this time (1797), placed a ligature on what is called the external iliac artery; and as he seldom touched anything which he did not improve, he made an important modification in the mode of proceeding.
subsequent experience, it is true, has, in some measure, rendered that improvement no longer necessary; yet, whenever circumstances arise which lead to any material disturbance of the artery from its situation, we apprehend the caution of abernethy in tying it in two places close to its connection with the surrounding parts, is a valuable condition.
he also sent, about this time, an ingenious paper to the royal society, on certain small openings into the cavities of the heart. they are called the "foramina of thebesius," from an anatomist who particularly described them. this is to us one of the prettiest of his physiological contributions. the facts are stated with great simplicity, their relations to disease beautifully pointed out, and the inference from the whole very striking, as being in harmony with the facts whence it is deduced. abernethy's idea being, that the holes were for the purpose of obviating excessive repletion of the nutrient vessels of the heart, by allowing them to relieve themselves by pouring a portion of their blood through117 these holes into the general mass of the circulation. it could hardly, however, be made interesting to the general reader without going into the subject more than is suited to our present object.
in 1799, abernethy's reputation had gone on rapidly increasing. his numerous pupils, too, had become the media for frequent consultations, in addition to those which arose from his own connection, and his reputation with the public.
he now moved from st. mildred's court, and took the house in bedford row. this was some time previous to october, 1799, the september of that year being the last time his name appears on the rate-book of st. mildred's court. he never again changed his professional residence. the move was an important step, but it was only the precursor to one still more interesting.
in the january of the following year, an event occurred which seldom fails to exert a greater influence on a man's future prospects and happiness than any other. this was no less than his marriage—of which we must say a few words in a separate chapter.
