"MY BOOK" CONTINUED.
"La première chose qui s\'offre à l\'Homme quand il se regarde, c\'est son corps. Mais pour comprendre ce qu\'elle est, il faut qu\'il la compare avec tout ce qui est au-dessus de lui, et tout ce qui est au-dessous, afin de reconno?tre ses justes bornes."—Pascal, Pensées, Nature des Hommes, vol. ii, p. 57.
Abernethy, in impressing any anatomical fact, would sometimes say that we carried about with us in our own bodies excellent means of refreshing our impressions on many points of anatomy; but we may say this in a much more extensive sense with regard to the interpretation of that for which anatomy is alone useful—namely, the uses or functions of the body. It would be very possible for any observant person, who was moderately versed in the ordinary principles of correct reasoning, to detect many defects in medical investigations and practice; in the correction of which many of Abernethy\'s practical contributions consisted; but the mind, restlessly impatient to arrive at conclusions, often overlooks the most important facts, and deduces inferences directly from the evidence of the eye or other senses, without submitting it to such test as the intellectual faculty can alone supply. Nothing can exceed the mischief of this in serious matters, nor the absurdity of it, when we think awhile.
We should hardly refrain from laughter if we saw a man try to see with the point of his nose, or endeavour to examine the odour of a rose by his ear, or to listen with his eye; yet this is not a whit more absurd than to try to deduce conclusions from the impressions furnished by the eye, which can alone be afforded by the rational faculty. Nothing is more common than this sort144 of fallacy, nothing more easy than its correction; but then people must bestow at least a little of that time on their highest faculties which they so lavishly expend on inferior powers. How much time we consume, for example, in the study of various languages—those instruments for the communication of ideas—as compared with that bestowed on the collecting and marshalling of ideas themselves; which is little better than grasping at the shadow, and losing the substance; or, to use a humorous illustration, like a friend of our own, who, having a new dog, sent his servant forthwith to purchase sundry articles for him, in the shape of kennel, chains, engraved collars and food; all of which, at some expense, he safely accomplished to his master\'s satisfaction, expressing his sorrow at the same time for having accidentally lost the dog!
It is curious, however, to observe how the real business of the human mind is shadowed forth in the very abuses of its powers; nothing so bad but it is charged with a certain quantity of good; no error so great but carries with it the element of its own correction. The mind in its greatest aberrations is followed by the shadow of its real duty, which as it were waits on the time when clearer views shall burst on it. Nothing shows the real tendencies of mind more than its restless desire to arrive at some conclusion, some tangible evidence of its highest functions. It is the impulse of this instinct—the ungoverned abuse of a high faculty, impatient for illegitimate fruition—which lies at the bottom of much false reasoning, and which blinds men, even of great power, to obstacles which are luminously evident to the most ordinary capacity. Important as the next series of illustrations cited by Abernethy are, the conclusions he deduced from them were the necessary sequences of clear and correct reasoning on familiar and established facts.
The illustrations in question were those afforded by various cases of injuries of the head, in which certain consequences, however exceptional they may be, are too commonly referred to the abstract nature of the injury. We see that a man has a blow, we see that he does not recover in the usual way in which we have known many others to recover; but we do not, perhaps,145 consider that if a similar—nay, perhaps an identical force produces very different effects in different cases, the cause will probably not be in the nature or direction of the force so much as the condition of the body. Now the value of these cases of Abernethy\'s consists, first, in impressing the influence of this condition as modifying—in other words, sustaining—the disturbance consequent on injuries (in their origin) purely mechanical; and secondly, in showing that, in the cases in question, that condition depended on a disordered state of the digestive organs. We hardly know any cases more valuable than those in question. When a patient receives a blow, and, the immediate consequences having subsided, there still remains an impairment of sense or motion, the most usual thing, and no doubt very often the true view, is to refer it all to lesion of nervous structure. It is therefore of the highest consequence to know the facts of these cases. They not only prevent the hasty institution of treatment which would be injurious; not only secure the patient from being abandoned in despair; but supply at the same time the clues to a rational treatment, and the hope of a favourable issue.
There can now be few observant surgeons who have not met with cases in illustration of these circumstances; and yet I know not to whom the perusal of Mr. Abernethy\'s cases might not be useful. It is not without regret that I forego transcribing at least one of them; forgetful how impossible it is to do Abernethy full justice in a work intended for all readers. In his "Book," the cases in question begin at page 97, and occupy but a few pages.
The next class of cases, from which Abernethy illustrates the prevailing influence of the digestive organs, receives additional importance from the imperfect manner in which the phenomena have been interpreted in a vast variety of diseases; like small-pox and others, ascribed to the action of particular poisons. We may possibly have an opportunity of saying something more on this subject; but we may remark that when any disease has been presented to the physician or surgeon, supposed to be the result of specific poisons, it is just the last case in which any special attention is paid to the digestive organs. Now Abernethy observed146 that disorders of the digestive organs would sometimes produce diseases resembling maladies said to result from specific poisons. This is about the first indication or hint of that which, duly carried out by an advancing science, will, we trust, ere long, demonstrate what to us has long appeared only part of a general law. Of this we may by and by say a little more, when we endeavour to show the small quantity of truth which there is mixed with some of the prevailing errors; and how their occasional success results from blundering, as it were, on small portions of the principles enunciated by Abernethy.
In the meantime, we may refer to the illustration afforded by small-pox of the remarkable influence of the digestive organs in diseases called specific. We adduce this, because it is one which is popularly familiar, and a disease that, had it been studied under any but one particular phase, would have proved, of all others, the most instructive. There is no malady, under certain circumstances, more extensively fatal.
In the Spanish conquest in America—a history scarcely less interesting in a medical than in a moral point of view—it seems that not all the cruelties of the Spaniards were more destructive than the small-pox. In less than a century after the arrival of Columbus, it was computed that it had destroyed more than half the population; and in one year (1590), it so spread along the coast of Peru, that it swept away nearly the whole of the Indians, the Mulattoes, and the Mestichos, in the cities of Potosi and De la Hay31.
As is well known, before the discovery of vaccination, persons were inoculated with the small-pox, because it was found that the disease could be thus rendered comparatively harmless; whilst, if it was taken naturally, as it was termed, it was always serious, and too frequently extremely fatal. The preparation for inoculation consisted of measures addressed to the digestive organs. Now the effect may be judged of by this fact: Inoculation was at first violently opposed; and, in reply to the alleged safety of it,147 an opponent wrote to prove that one in one hundred and eighty-two had died of it. I wish we could say so of many other diseases.
That such persons had, nevertheless, the genuine malady, was proved by the fact they were capable of infecting others (unprepared) with the disease in its most malignant form. But our notions of the mode in which the laws of the animal economy deal with injurious influences of this kind, are mischievously conventional. What quantities, for example, of mercury, in its different forms, have been administered in almost all diseases; and yet unquestionably there is a great deal of false reasoning in regard to this poison. Effects are attributed to it as mercury, which only belong to it in its general character of an injurious agent. All the (so-called) specific effects of it, most of which are become popularly familiar, may occur without any mercury at all. We have seen them induced by aloes, by scammony; and in a case where no medicine had been given, and where the only detectable poison was one which was to be sure bad enough, an enormously loaded liver.
We are obliged to say but little here in connection with this subject. Abernethy\'s cases were very important in relation to the influence of the digestive organs, although he did not see the generalization to which, as it appears to us, they help to conduct the pathologist. The subject is too extensive for discussion here. We will attempt something of a popular view of it, when we endeavour to explain the fallacy to which we have already referred.
Abernethy next adduces various illustrations from cases of other diseases; as indurations, tumours, carbuncles, scrofulous affections, and others; in proof of the dependence of a "numerous and dissimilar progeny" of so-called local diseases, on that "fruitful parent," disorder of the digestive organs. Of one of the most interesting and remarkable cases of tumour, Mr. Abernethy did not live to see the termination. It was of a lady who consulted him previous to the proposed infliction of an operation. She had been recommended by my father, in the country, to consult Abernethy before submitting to it; because he disapproved of it, as did Abernethy—not because they doubted of the nature148 of the disease, but because it was not confined to the part on which it was proposed to operate.
The lady used to call on Abernethy when she came to town; and after his death she came to me—as she said, just to report her condition. She had at times various disturbances of her digestive organs; but always from some imprudence; for, although habitually very simple in her habits, she would be sometimes careless or forgetful.
She died at a very advanced age—between seventy and eighty—but there had been no return of the disease for which she had originally consulted Abernethy, nor had she undergone any operation. It is a significant circumstance, too, that she had a sister who died of cancer.
The whole of the cases are, however, scarcely less valuable. In the fifth section, he treats of disorders of parts having continuity of surface with the alimentary canal, certain affections of the nose, of the eye, and of the gullet or ?sophagus. His observations on the latter are especially valuable. They strike at that meddling practice which is too common in the treatment of diseases of these parts. Many of us have recommended a practice which, without neglecting either, relies less on manipulatory proceedings, and more on measures directed to the general health, in such cases; as producing effects which are not to be obtained by other means; but, if we are to judge from the medical periodicals, without much success; so inveterate is the habit of imagining that, whatever the causes of disease may be, if the results be but mechanical, mechanical means can alone be applicable. Public attention, and the perusal of such cases as those of Abernethy, can alone correct these errors.
Lastly, he describes the results of his dissections as bearing on the whole subject. Here he shows, that whilst disordered function may take place coincidentally with, or as a consequence of, change of structure, yet that such change, so as to afford visible or detectable departures from natural appearances, is by no means necessary, in organs which, during life, had afforded the most incontrovertible evidence of impaired function. He also shows that disease has terminated in disorder which had its original seat149 in the digestive organs. And again—that, in cases where the cause of death had been in the abrogated function of the brain, he found no actual disease in that organ, but in the abdominal viscera. He very justly observes that the conclusions he has drawn can be neither ascertained nor disproved by anatomical evidence alone. He mentions especially, and illustrates by a remarkably successful case, how diseases of the lungs may be engendered by disorders of the digestive organs, and entirely subdued by correction of that disorder.
He speaks also suggestively of the possibility of that which is certainly now an established fact. He says: "In cases of diseased lungs, where no disease of the digestive organs is discovered, yet considerable disorder does exist, and may continue for many years without any organic disease being apparent; it is possible that such disorder may excite disease of the lungs, and thus produce a severer disease of the latter organs than what existed in the former. Accurate attention to the digestive organs may determine this important subject, and lead to the prevention and cure of the sympathetic diseases which I have mentioned." "This attention must not be merely of that general kind which adverts only to the quality of the ingesta, &c., but one which more strictly observes whether the viscera" (that is, reader, not merely the stomach, not merely the digestive organs, but the whole viscera of the body) "and whether these secretions are healthy or otherwise." After speaking of the heart also, as affected by the digestive organs; and of the infinity of diseases which arise from the reciprocal disturbance excited between them and the brain;—he says: "But even these are not the worst consequences. The disorder of the sensorium, excited and aggravated (by the means which he has described), affects the mind. The operations of the intellect become enfeebled, perplexed, and perverted; the temper and disposition, irritable, unbenevolent, and desponding. The moral character and conduct appears even to be liable to be affected by these circumstances. The individual in this case is not the only sufferer, but the evil extends to his connections and to society. The subject, therefore, appears to me to be of such importance, that150 no apology need be offered for this imperfect attempt to place it under general contemplation." Here is that suggestion which, when carried out, leads to the detection of cases of insanity which depend on disturbances of the digestive organs.
Lastly, as if, notwithstanding his own previous attention to the important question of the influence of the digestive organs in disease, he felt that the inquiry had grown upon him in consequence of Mr. Boodle\'s endeavour to concentrate his attention to the subject, he concludes by expressing his past obligations to Mr. Boodle; for he says, with admirable modesty and candour, "for Mr. Boodle first instructed me how to detect disorders of the digestive organs, when their local symptoms were so trivial as to be unnoticed by the patient." He urges Mr. Boodle to publish also his own observations on the subject, because any remarks from one who observes the progress of disease "with such sagacity and accuracy, cannot but be interesting." We are quite aware how feeble our attempt has been to do justice to this admirable book. But nothing can do that but a careful study of the various principles which it either suggests, dimly shadows forth, or deeply and beautifully unfolds.
Through not a very short life, we have had ample opportunity of testing these principles by the bedside, and of endeavouring to connect some of them with the laws in obedience to which they occur; and we are free to declare our impression that when the book is studied with the requisite previous knowledge, and freedom from preconceived opinion; and when tested and carried out in principle, as distinguished from any adhesion to mere matters of detail; we think it infinitely more valuable than all other professional works whatever. In examining the truths it unfolds, or in our humble endeavours elsewhere at a more analytical or extended application of them, like Abernethy, we have rested our reasoning wholly on facts and observations which are acknowledged and indisputable.
Whilst other views have only led to a practice in the highest degree empirical, or, what is worse, conjectural, those of Abernethy\'s lead often directly, but always when duly studied, to a practice at once clear, definite, and in the sense in which we shall151 qualify the word "positive,"—that is, one which gives us the power (when we really have the management of the case) of predicting the success or failure; which is at least a ripple indicative of a coming science.
In order, however, to carry out this clearly, we shall at once add what we think necessary to the profession and the public on the subject. The general relation of Abernethy\'s labours to a real and definite science will be better developed in our concluding Summary; when we may have an opportunity of stating what further appears to have been done, and what is yet required. It will have been perhaps already observed that Abernethy\'s views involve a few very simple propositions: first, that disturbance of a part is competent to disturb the whole system; and conversely, that disturbance of the whole system is competent to disturb any part. That the disturbance may commence in the brain or nervous system, may then disturb the various organs, and that these may again by reflected action disturb the brain, and so reciprocally; and that in all these cases tranquillity of the digestive organs is of the very first consequence; not merely from its abstract importance, but from the influence it exerts on the state of the nervous system.
With respect to any influences immediately directed to the nervous system, these we apprehend to be few and simple; some kinds of medicine, are, no doubt, in particular cases useful, none are susceptible of general application. None of them are certain; and sedatives of all kinds, which appear to have the most direct influence on the nervous system, either require to be employed with the utmost caution, or are in the highest degree objectionable. But there are other direct influences, certainly; and very important they are. Quiet, avoidance of disturbing external impressions, whether of light, sound, temperature, &c. whether in fact of mind or body; but, in the majority of mankind, how few of them we can, in a strictly philosophical sense, command. We are therefore driven to other sources of disturbance; and in the digestive organs we find those on which we can exert great influence, and in which tranquillity, however procured or under whatever circumstances, is certain, pro tanto, to relieve the whole152 system. This Abernethy attempted, and with a success which was remarkable in no cases more than those which had resisted all more ordinary modes of proceeding; by general measures, by simplicity of diet, by occasional solicitation of this or that organ, by air and exercise, and measures which were directed to the general health. No doubt in some cases he failed, and so we shall in many; but let us look boldly at the cause, and see whether we do not fail a great deal more from our own ignorance than from any natural impossibility.
To examine the question, we must for the moment forget our admiration of Abernethy; be no longer dazzled by his genius, but look only to our duty; endeavour to discover his defects, or rather those of the state of the question when he left us, and see what further investigation has afforded in aid of supplying them.
In the first place, we must examine a little further that proposition which we have seen both in Hunter and Abernethy under different forms. Hunter says the disturbance of the organ sympathizing is sometimes more prominent than that of the organ with which it sympathizes. Abernethy says that the organ primarily affected is sometimes very little apparently disturbed, or not even perceptibly so.
Now, from both these statements, we find that there may be no signs in the primarily affected organ; which, practically rendered, is nothing more or less than saying that in many cases we must not seek for the primarily affected organ where the symptoms are; and this is a great fact: because, although it does not necessarily teach us what we must do, it exposes the broken reed on which so many rely. Now the further point, which, as we would contend, time and labour have supplied, is first this—that what Hunter had mentioned as one feature in the history of the sympathies of different organs, and Abernethy as an occasional or not unfrequent occurrence, is, in disorders of any standing, and with the exception of mechanical injury, in fact the rule—the symptoms of disorder being almost never in the primary organ; nay, even organic change (disease) is for the most part first seen in a secondarily affected organ. In regard to primarily affected parts, the skin only excepted, they will be found, in the vast majority of cases, to be one or other of the digestive organs.
153
I will endeavour to render the cause of this intelligible. A minute examination of what happens in a living person, especially if it be extended to some thousands of cases, will soon disclose to the most unlettered person a few instructive facts, showing that Nature has a regular plan of dealing with all injurious influences, which, however various many of the details may be, is in general character exquisitely simple, surprisingly beautiful, and intelligibly conservative; and that the various modes on which she exercises this plan, from the cradle to the gr............