"Utiliumque sagax rerum."
?
Hor.
In estimating the practical penetration1 and clear judgment2 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 intelligible3 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 apparently4 easy, that one wondered how it happened that nobody could ever do it so well.
But when we saw him placed in juxtaposition5 with other men, these peculiarities7, 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 dedicated8 to his old87 master, Sir Charles Blicke. The third, the subject of our present consideration, he inscribed9 to his early instructor10 in anatomy11, Sir W. Blizard. The dedication12 is straightforward13 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 secondly14, it derives15 a peculiar6 interest from the parallelism it suggests between Abernethy and one of the most distinguished16 surgeons of France, the celebrated17 Pierre Joseph Desault—a parallelism honourable18 to both, yet remarkably19 instructive as to the superior discriminative20 powers of Abernethy. Desault's pupil, Bichat, himself one of the most accomplished21 anatomists of his time, has left an eloquent22 eulogium on Desault, which, although somewhat florid, is by no means above his merits. He says he was the father of Surgical23 Anatomy in France; and certainly few men evinced more sagacity, in that immediate24 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, ardent25 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 premier26 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 appreciation27 of the immediate results of surgical proceedings28; and as these were definite, successful, doubtful, or abortive30, he either persevered31 with a characteristic tenacity32 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 applied33 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 faculty34, which, in endeavouring to interpret the meaning of phenomena35, can point out the true question which it is desired to ask of nature, as well as the mode of inquiry36.
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 sufficiently37 alarming in themselves, but the actual cause of which many circumstances sometimes concur38 to complicate39 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 intoxicated40. Then, again, patients are presented to the surgeon, in different cases, at extremely different intervals41 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 modifications42 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 instinctively43 suggests the expediency44 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 depressed45, to its natural level. In many instances, the proceeding29 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), mischievous46. 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 adoption47 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 propriety48 of the operation, he practically for ever abandoned it; thus at once cutting the knot he felt it difficult or90 impracticable to unravel49. As this was many years before his death, the principal argument on which he supported the relinquishment50 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 eminently51 characteristic of what people call "a practical man;" but, after all, it is not very sound reasoning. Now, here it was that the discriminative excellence52 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 precipitate53, we might find that they would again subside54, 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 restrictions55 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 uncertainty57 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 vessels58, 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 vascular59 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.
91
He next proceeds to consider the distinction between those cases in which the brain has been shaken merely (concussion60), 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 discordant61 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 stimulation62 excite, the depressed powers; or, by judicious63 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 derived64 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 lamentable65 omission66 of facts in the record of cases, are all worthy67 of profound attention. Equally excellent is the ingenuity68 with which he attempts the distinction between the cases of concussion, and compression, of the brain. His endeavour to discriminate56 the cases in which the effusion, or inflammatory action, respectively, affect one or other membrane69, 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 artery70, 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 nostril71. In concluding this remarkable72 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 disorder73 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 entirely74 overlooked."
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1
penetration
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| n.穿透，穿人，渗透 | |
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2
judgment
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| n.审判；判断力，识别力，看法，意见 | |
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3
intelligible
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| adj.可理解的，明白易懂的，清楚的 | |
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4
apparently
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| adv.显然地；表面上，似乎 | |
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juxtaposition
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| n.毗邻，并置，并列 | |
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6
peculiar
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| adj.古怪的，异常的；特殊的，特有的 | |
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peculiarities
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| n. 特质, 特性, 怪癖, 古怪 | |
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dedicated
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| adj.一心一意的；献身的；热诚的 | |
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inscribed
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| v.写，刻( inscribe的过去式和过去分词 )；内接 | |
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instructor
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| n.指导者，教员，教练 | |
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anatomy
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| n.解剖学，解剖；功能，结构，组织 | |
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dedication
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| n.奉献，献身，致力，题献，献辞 | |
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13
straightforward
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| adj.正直的，坦率的；易懂的，简单的 | |
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14
secondly
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| adv.第二，其次 | |
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derives
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| v.得到( derive的第三人称单数 )；（从…中）得到获得；源于；（从…中）提取 | |
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16
distinguished
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| adj.卓越的，杰出的，著名的 | |
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17
celebrated
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| adj.有名的，声誉卓著的 | |
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18
honourable
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| adj.可敬的；荣誉的，光荣的 | |
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remarkably
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| ad.不同寻常地，相当地 | |
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discriminative
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| 有判别力 | |
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accomplished
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| adj.有才艺的；有造诣的；达到了的 | |
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eloquent
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| adj.雄辩的，口才流利的；明白显示出的 | |
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surgical
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| adj.外科的，外科医生的，手术上的 | |
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immediate
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| adj.立即的；直接的，最接近的；紧靠的 | |
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ardent
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| adj.热情的，热烈的，强烈的，烈性的 | |
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premier
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| adj.首要的；n.总理，首相 | |
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appreciation
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| n.评价；欣赏；感谢；领会，理解；价格上涨 | |
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proceedings
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| n.进程，过程，议程；诉讼(程序)；公报 | |
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proceeding
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| n.行动，进行，(pl.)会议录，学报 | |
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abortive
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| adj.不成功的，发育不全的 | |
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persevered
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| v.坚忍，坚持( persevere的过去式和过去分词 ) | |
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tenacity
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| n.坚韧 | |
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applied
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| adj.应用的；v.应用，适用 | |
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faculty
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| n.才能；学院，系；(学院或系的)全体教学人员 | |
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phenomena
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| n.现象 | |
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inquiry
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| n.打听，询问，调查，查问 | |
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sufficiently
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| adv.足够地，充分地 | |
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concur
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| v.同意，意见一致，互助，同时发生 | |
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complicate
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| vt.使复杂化，使混乱，使难懂 | |
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intoxicated
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| 喝醉的，极其兴奋的 | |
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intervals
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| n.[军事]间隔( interval的名词复数 )；间隔时间；[数学]区间；（戏剧、电影或音乐会的）幕间休息 | |
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42
modifications
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| n.缓和( modification的名词复数 )；限制；更改；改变 | |
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instinctively
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| adv.本能地 | |
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expediency
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| n.适宜；方便；合算；利己 | |
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depressed
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| adj.沮丧的，抑郁的，不景气的，萧条的 | |
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mischievous
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| adj.调皮的，恶作剧的，有害的，伤人的 | |
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adoption
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| n.采用，采纳，通过；收养 | |
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48
propriety
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| n.正当行为；正当；适当 | |
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49
unravel
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| v.弄清楚（秘密）；拆开，解开，松开 | |
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relinquishment
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| n.放弃；撤回；停止 | |
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eminently
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| adv.突出地；显著地；不寻常地 | |
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excellence
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| n.优秀，杰出，(pl.)优点，美德 | |
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53
precipitate
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| adj.突如其来的；vt.使突然发生；n.沉淀物 | |
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54
subside
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| vi.平静，平息；下沉，塌陷，沉降 | |
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55
restrictions
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| 约束( restriction的名词复数 )； 管制； 制约因素； 带限制性的条件（或规则） | |
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56
discriminate
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| v.区别，辨别，区分；有区别地对待 | |
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uncertainty
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| n.易变，靠不住，不确知，不确定的事物 | |
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58
vessels
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| n.血管( vessel的名词复数 )；船；容器；（具有特殊品质或接受特殊品质的）人 | |
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vascular
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| adj.血管的，脉管的 | |
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concussion
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| n.脑震荡；震动 | |
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discordant
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| adj.不调和的 | |
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stimulation
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| n.刺激，激励，鼓舞 | |
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judicious
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| adj.明智的，明断的，能作出明智决定的 | |
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derived
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| vi.起源；由来；衍生；导出v.得到( derive的过去式和过去分词 )；（从…中）得到获得；源于；（从…中）提取 | |
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lamentable
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| adj.令人惋惜的，悔恨的 | |
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omission
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| n.省略，删节；遗漏或省略的事物，冗长 | |
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worthy
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| adj.(of)值得的，配得上的；有价值的 | |
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ingenuity
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| n.别出心裁；善于发明创造 | |
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membrane
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| n.薄膜，膜皮，羊皮纸 | |
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artery
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| n.干线，要道；动脉 | |
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71
nostril
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| n.鼻孔 | |
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remarkable
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| adj.显著的，异常的，非凡的，值得注意的 | |
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disorder
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| n.紊乱，混乱；骚动，骚乱；疾病，失调 | |
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entirely
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| ad.全部地，完整地；完全地，彻底地 | |
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