Outline of a natural system of medical science

FIRST PRELIMINARY LECTURE TO THE COURSE OF PATHOLOGY AND THE PRACTICE OF MEDICINE; EXHIBITING THE OUTLINE OF A NATURAL SYSTEM OF PATHOLOGY, MEDICINE AND THE MATERIA MEDICA.

Gentlemen,

I shall not, on the present occasion, detain you with prefatory remarks; but, as a fairer proof than any I can adduce, of the necessity of such a course of lectures as I now propose, shall merely repeat to you, upon this subject, the sentiments of one whom genius in the science and skill in the art of medicine have elevated high in his profession, and whose eloquence is not less admirable than his professional abilities.

“To ally anatomy,” says he, “more closely with surgery, to connect the art more intimately with the science from which it flows, seems to me a task as yet imperfectly accomplished, though of the very highest importance.—Anatomy is not made interesting to the pupil as the basis of our reasoning on disease, the rule of our prognostications, the sole guide in operating: He is taught to know the parts and remember their names, and then he is dismissed from the school; and of this school we are all pupils, abandoned early in our career, left to learn, in the hurry of practice, the very principles of the science!—The anatomy of surgery differs widely from that taught in the schools.—Pathology, which ought to unite science with art, is a sort of neutral ground betwixt the two provinces of anatomy and surgery, little regarded on either hand.”

To obviate these important defects is the very object of the present lectures.—I shall assiduously study to supply all of them; I shall, after delivering a natural system of medical science in general, the tendency of which is not to controvert one established fact, but by pointing out their relations, to consolidate, to simplify and if possible to increase the amount of our knowledge on all the subjects of medicine—I shall, I say, after this, enter into all its details, point out the relative situation of those parts which perpetually come under the care of the surgeon, explain all the variety, of the applications of an original, fundamental and universally applicable principle of surgical operation, and endeavour to direct the student, while, with his own hand, he performs each of these operations.

Public bodies, Gentlemen, as well as individuals, have too often opposed the progress of science.... But, when have they been able to impede it?—Never. The iron grasp of tyranny and the intrigues of malice are alike innocuous to truth; the progress of science is irresistible and triumphant.

On the present occasion, I feel it my duty to propose a new system, nor do I expect very different treatment; for though the gun of the soldier and the anathema of the priest be no longer connected, the malice of the interested and the intrigues of party occupy their place: the former were the measures of a barbarous; the last are those of a half-polished age. Fortunately, however, far from being formed to fear opposition—I court it.

The following sketch of a natural system of medical science is founded on the strict basis of physiology, and is, I trust, calculated to place, in a new and more interesting point of view, the beautiful relations which subsist between the sciences of anatomy and physiology and the art of medicine, as well as to lay the foundation of a more rational system of medical science.

I do not, however, make this statement without a feeling of the utmost deference to the labours of the celebrated Cullen and Brown—the authors of the existing systems and of innumerable observations of the highest value in medical science. Nothing less than the firmest conviction of the truth and simplicity of the system I am about to propose, could have induced me to deliver it.

First, however, I shall proceed to exhibit the present state of medical science.

No system of the medical art can be just in its principles, and perfect in its application, which does not consider the derangement of the mechanical, vital, and intellectual functions distinctly, and trace each disease to the operation of its cause in the derangement of that particular function which was first produced, and which led to the derangement of all the rest.

It has been the fate of all systems to be founded upon partial views of the functions. The system of the celebrated Cullen, for example, was founded merely upon the vital functions, and even upon a very limited portion of them—the state of the capillary vessels. Considering its extent, however, it was valuable.

The system of Brown, likewise, was similarly founded merely upon the state of the intellectual or nervous functions. That system, therefore, although worthy of consideration, is not founded upon a view of all the animal functions, and consequently does not rationally account for all their derangements in disease. The basis of its author’s discovery was his mistaking the mere elasticity or reaction of matter for a peculiar property of living bodies, which he termed excitability. For excitability, when it seems to have been exhausted, is apparently restored by still stronger stimuli, upon the very same principle that greater pressure brings into action the remaining elasticity of a spring which had already lost some portion of it.

But what is worse, Brown totally forgot that matter has other properties, and that the constitution of animals admits of other derangements than those affecting their elasticity or their excitability. Extension, for instance, another property of matter, may be destroyed in the living body, by fracture, rupture, &c.; and there evidently it is not excitement that is first produced, or that is worthy either of the first or of the greatest consideration. Brown’s doctrine, then, refers chiefly to the state of the nervous functions. Its chief merit is, that it involves a great portion of their pathology. It is because it does so, that men of ingenuity have often embraced it; and it is in reality because it did not do more—because it did not involve the pathology of the other two classes of functions, that men of much observation opposed it; and that even many of those men of genius who, throughout Europe, had adopted it, were afterwards forced, they scarce knew why, to abandon it.

Certainly, in all diseases, the nervous functions must be affected; but they may be affected through the vital or mechanical functions—by means, for instance, of an aneurism or a fracture. A fracture or an aneurism, however, have no existence as diseases under the Brownonian system. These are whimsically, absurdly, termed stimuli; not diseases, but mere causes of disease; and the attention of the physician is, upon the principles of that hypothesis, ridiculously turned from the immediate disease to others depending upon it, to the state of the nervous functions. And for what purpose? Not, by their aid, as mere accessary and subordinate considerations, which in this case they really are, to regulate the disease of the mechanical or vital functions, from the very first the most obvious, but in order to discover the very existence of any disease; as if fracture or aneurism in themselves were not alarming diseases, independently of their effects upon other parts of the system, as if the injury done to the mechanical functions, to loco-motion, was less worthy the name of disease than that done to the intellectual functions, to nervous motion. Yet, in practice, the Brownonian, even supposing that the nervous system were little or not at all affected, would instantly abandon his hypothesis, and demonstrate its inapplicability, by recurring to the injury of the mechanical functions, by setting the fractured limb, or operating for the aneurism. In the first of these instances, indeed, the primary disease, almost the only one worthy of consideration, is the injury done to the mechanical functions, to loco-motion, which has absolutely nothing to do with excitability or excitement.

It is not my view, however, intirely to exclude these systems, or to depreciate their real value, but to show that they merely form portions of a natural system. Still no system of the medical art can be perfect, which does not consider the derangement of the mechanical, vital and intellectual functions distinctly, and enable us to trace each disease to the operation of its cause in the derangement of that particular function, whether mechanical, vital, or intellectual, which was first produced, and which led to the derangement of all the rest.

These opinions I may support by the observations of others. “Efforts laborieux et multipliés,” says Pinel, “de Sauvages, Cullen, Sagar, Vogel, Linné, Nietzki, Selle, Van-Denheuvell, &c. pour distribuer toutes les maladies connues en classes, en ordres, en genres, en especes, à l’exemple des botanistes, et toujours pour résultat une extrême surcharge du tableau, une classification a bitraire et vaccillante, des affections symptomatiques prises pour des maladies primitives, une multiplication excessive, des unes et des autres par des complications sans nombre des maladies, une sorte d’impossibilité avouée d’obtenir un ensemble régulier qui ne porte que sur quelques points fondamentaux, et qui vienne se placer sans efforts et sans confusion dans la memoire.”

I cannot better explain my opinion of the present state of medicine than by using, respecting it, the language of Lord Bacon, which is, at this moment, as applicable to it, as it was when first written. “We see,” says he, “the weakness and credulity of men is such, as they will often prefer a mountebank or witch, before a learned physician, and, therefore, the poets were clear-sighted in discerning this extreme folly when they made Æsculapius and Circe, brother and sister, both children of the sun.—For, in all times, in the opinion of the multitude, witches, and old women, and impostors have had a competition with physicians. And, what followeth? Even this; that physicians say to themselves, as Solomon expresseth it upon an higher occasion, If it befall to me as it befalleth to the fools, why should I labour to be wise? And, therefore, I cannot much blame physicians, that they use commonly to intend some other art or practice which they study more than their own profession. For, you shall have of them, antiquaries, poets, humanists, statesmen, merchants, divines, and in every of these better seen than in their own profession; and, no doubt, upon this ground, that they find that mediocrity and and excellence in their art maketh no difference in profit or reputation toward their fortune; for the weakness of patients and sweetness of life, and nature of hope, maketh men depend upon physicians with all their defects.”

But Lord Bacon has assigned an amply sufficient reason for these circumstances. In another place, he says, “Medicine is a science which hath been, as we have said, more professed than laboured, and yet more laboured than advanced, this labour having been in my judgment, rather in circle than in progression. For I find much iteration, but small addition.” Now it is, in reality, this profession without labour, this labour without advancement, so well expressed by Lord Bacon, this iteration without addition, which is the real and sufficient cause (overlooked by him) of the poets so properly making Æsculapius and Circe, brother and sister, and of the world uniformly placing witches, old women and impostors in competition with physicians. And again his lordship, with equal justice, says, “in the inquiry of diseases, they do abandon the cures of many, some as in their nature incurable, and others as past the period of cure; so that Sylla and the triumvirs never proscribed so many men to die, as they do by their ignorant edicts, whereof numbers do escape with more difficulty, than they did in the Roman proscriptions. Therefore I will not doubt to note as a deficience, that they inquire not the perfect cures of many diseases, but, pronouncing them incurable, do enact a law of neglect and exempt ignorance from discredit.”

It therefore becomes proper to ascend to the cause of the little success which has hitherto attended medical investigation, and to attempt, by the removal of that cause, to accelerate its progress, and, by increasing the success, to increase the respectability of the art.

The grand cause which has hitherto retarded the progress of medicine, has been the total want of a general principle, and this want has arisen from the very low state of physiological theory.

It has ever appeared to me that a sufficient distinction has not been made between diseases as affecting various functions, which to the most superficial observer seem to be very different in their nature. It would appear, at first sight, that, instead of almost uniformly applying mental remedies to mental diseases, the physician not only does not distinguish what stages and parts of the same disease are mechanical, what vital and what intellectual, which must uniformly be the case where all the functions are involved, but that he does clearly perceive such a distinction at all to subsist in any form or combination of disease.

The physician has also failed to attend to a correct arrangement of the various articles of the materia medica, which ought not to be considered merely as stimulant, sedative, &c. but as in reality operating upon different functions.

Besides these, there appear to be other subordinate objects of inquiry, which he has hitherto, to a certain extent, overlooked; namely, that medicines seem to be objectionable from the injury which they do to those functions which are the vehicles of their operation, the uncertainty also of their effects as influenced by association, the uncertainty of their continuance as dependent on the same and other causes, the difficulty of removing their bad effects, and the injury they do to the intellectual functions in making man entirely the creature of direct impression instead of reflection.

I shall now, then, proceed to point out the mode of obviating this state.

These seem to me to be points eminently worthy of consideration, and the best mode of obviating the objections they involve, is a greater attention to natural theory and arrangement.

But, in order perfectly to remedy these great defects, the cultivation of physiology is primarily necessary. As far as the accumulation of facts goes, it has, however, already been cultivated, and that most assiduously. But before these accumulated facts can afford a principle of medicine, they must afford a theory of physiology, and, before they can afford this, they must be arranged according to their relations to each other.

I may here observe, that the sciences alone afford theories, the arts admit merely of principles upon which these reasonings or theories are applied to the wants of man. Thus, in every step of their progress, the arts must implicitly depend upon the sciences.

Now medicine is purely an art and admits of a principle derived from physiology by which the theories of that science may be applied to the cure of diseases.

As, however, no general theory of physiology exists, it becomes necessary to inquire what systematic arrangement can be given to its facts, as strictly founded on those of anatomy, in order to obtain one. And I know none so unexceptionable as that arrangement which I have already publicly delivered, nor any general theory so rational as the one which results from it.

I shall now, therefore, restate these arrangements, and then try their applicability to the medical art.

Anatomy I divide into three parts, namely, that which considers the mechanical or loco-motive organs, that which considers the vital organs, and that which considers the intellectual organs.

Under the mechanical or loco-motive organs, I class, first, the bones which support the rest of the animal structure; second, the ligaments which unite them; and, third, the muscles which move them.

Under the vital organs, I class, first, the organs of digestion, the absorbent surfaces, and the vessels which absorb from these surfaces; second, the heart, lungs and blood-vessels which derive their contents (the blood) from the absorbed lymph; and, third, the organs of secretion which separate various matters from the blood.

Under the intellectual organs, I class, first, the organs of sense, where impressions take place; second, the brain or organ of judgment, where these excite ideas; and, third, the nerves, where volition results from the last.

This is a natural arrangement of the anatomy of animals, and its peculiar simplicity is illustrated by its involving, in application, that of minerals and vegetables, and by its being capable of instant adaption to physiological science.

In order to arrange animal physiology, it is only necessary to substitute the term “functions” for “organs;” and that science will likewise involve, in application, the physiology of mineral and vegetable bodies, and be, in its turn, capable of instant adaption to medical science.

Thus, the functions also are divided into mechanical, vital and intellectual.

The mechanical functions are subdivided into that of support, that of connection and that of loco-motion.

The vital functions are divided into that of absorption, that of circulation and that of secretion.

The intellectual functions are divided into that of sensation, that of mental operation and that of volition.

In order to arrange medical science, for the term “healthy functions,” the subject of physiology, it is only necessary to substitute the term, “diseased functions.”

The classes of disease are, therefore, like those of anatomy and physiology, three, namely, diseases of the mechanical or loco-motive functions, diseases of the vital functions, and diseases of the intellectual functions.

The orders of the first class, as affecting the functions of the bones, the ligaments and the muscles, are three, viz. diseases of support, diseases of connection, and diseases of loco-motion.

Those of the second class, as affecting the functions of the absorbent, circulating and secreting vessels, are likewise three, viz. diseases of absorption, diseases of circulation and diseases of secretion.

Those of the third class, as affecting the functions of the organs of sense, of the brain and of the nerves, are also three, viz. diseases of impression, diseases of judgment and diseases of volition.

The genera, under each order, consist of diminished, irregular and increased function.

This arrangement of disease likewise involves in application, that of minerals (if we choose to maintain the analogy and to give that term to mere injury of structure) and of vegetables, as well as animals. The first have what may be termed diseases of mechanical structure; the second have diseases of mechanical and vital functions; whilst the third have diseases of mechanical, vital and intellectual functions; corresponding with the observation that animals exist, vegetables exist and live, and animals exist, live and think.

Precisely in the same way, would I class the articles of the materia medica; first, as operating upon the mechanical, vital or intellectual organs, and then as either increasing, rendering irregular, or diminishing their action.

In this natural arrangement, I must again remark, that all its parts correctly correspond and beautifully flow from each other; while anatomy is the basis of physiology, physiology, in its turn, is the basis of medicine; the classification of one is applicable to the rest, and all of them at once involve mineral, vegetable and animal nature.

Such arrangement, as it lays the foundation of a new system of each, will, I trust, soon shed some light over anatomical, over physiological, and particularly over the dark paths of medical science; but it must be remembered, that this exhibits merely a sketch of the application of my general arrangement to medical science, and that sketch necessarily brief and deprived of every illustration. Yet, even after this sketch, I think I may add, in the words of Lord Bacon, that “the harmony of a science, supporting each part the other, is and ought to be the true and brief confutation and suppression of all the smaller sorts of objections.”

I shall now, however, further explain the principles upon which the natural system is constructed.

The correctness of this arrangement, as strictly founded on physiology, is confirmed by the following observations.

Disease is change of the healthy state and of the healthy action of parts. It is change of the state as well as of the action of parts, because action depends on state, life itself on organization, and it is only by affecting this state—the structure of the objects acting, that change of action can be produced. In fracture, as far as the bone is concerned, the action peculiar to it—loco-motion is affected; as the blood-vessels are ruptured, their action is affected; as the nerves are injured, their peculiar action is also affected.

Thus each has its peculiar action, and the action of each is affected through the medium of its structure; but the affection of the state and action of the vessels or nerves is not, in fracture, the primary disease, but only an extension of it to other parts or other functions, or, more properly, they are new diseases, because they affect new functions, and, though dependent upon it, are, in their nature, entirely different from fracture—the primary disease.

The action, for instance, of vessels in absorbing, circulating and secreting, so far as, in vegetables, for instance, the form and arrangement of their capillary tubes are concerned, or the continuation of the action commenced in these tubes, or the effusion of their contents when ruptured, is evidently independent of nerves; and I believe, were this principle traced further, it would be found to account for many of the actions of animal as well as vegetable parts. Whether true or false, however, it cannot materially affect the system. For whether their action is dependent on nerves or not, it is, strictly speaking, their own action, and, by injury, they are rendered incapable of performing it.

Disease may thus properly be defined, any change of the healthy state and healthy function of parts. If any one urge, that disease implies the action, not the state of parts, I grant it; but must observe that change of state is action, and change of healthy state is evidently morbid action or disease, whether it arises from within or without, whether suddenly from external and accidental causes, or more slowly within the body and in dependence upon other previous derangement.

Indeed to trace any disease back through previous derangement is actually to trace out other diseases, and to define any disease from others thus traced out, is to abandon those distinctions which separate the termination of one disease from the commencement of another.

If any one still assert, that disease is not change of the state but change of the action of parts, and urge that those accidents which depend on external causes, as fracture, considered in themselves, are not disease, I should say, were this even proved, it could only affect my arrangement by giving the term injuries, instead of diseases, to the first class. As, however, it seems to me that they may justly be named diseases, and that practically considered they are precisely the same, I shall retain that term. Thus, we shall have a fairer view of the interesting analogies which, as will be seen, exist between the animal, vegetable and mineral worlds.

Now, if disease consist in change of function, different diseases must either consist in different changes of the same function or in the changes of different functions; the former, viz. different changes of the same function, as being a more minute division, making evidently the genera which are subordinate; the latter, viz. changes of different functions, as being more general, forming the orders which include these genera.

From the inspection of the table, and a consideration of the nature of disease, it will appear, that whatever is commonly reckoned one disease, is generally, perhaps always, three; thus fracture is always accompanied by inflammation and pain; and while the simple fracture is a disease of diminished support, the inflammation caused by it is a disease of increased circulation, and the pain caused by it a disease of increased impression.

As individual diseases are not arranged under the table, I may, in order to render my meaning perfectly obvious, give one or two examples of this mode of classification. Thus with regard to the classes or first and most general divisions of disease, fracture is a disease of the mechanical functions, syphilis of the vital functions, and mania of the intellectual functions. With regard to the orders or second and less general divisions of disease in the last of these classes, amaurosis is a disease of impression or sensation, mania of mental operation, and paralysis of expression or volition. And with regard to the genera or subdivisions of disease in the second of these orders, fatuitas is a disease of diminished mental operation, mania of depraved mental operation, and vigilia of increased mental operation. Farther, with regard to the combination of disease under the last class, (sleep itself consisting in the quiescence of almost all the intellectual functions), dreaming consists chiefly in the quiescence of sensation, somnambulism chiefly in that of mental operation and incubus chiefly in that of volition.

With regard to the articles of the materia medica, or rather with regard either to external or internal applications, the correctness of my arrangement, as indicating their influence upon the different classes of organs, will, on the slightest consideration, appear equally evident; pressure, for instance, affects the mechanical, mercury the vital and opium the intellectual system. But, like the diseases which they remedy, it will appear, that each of these also affects all of the functions, though in a less direct manner than that which I have just now particularly pointed out as its object, and upon which the exact place of each in a systematic arrangement ought to depend.

It cannot, therefore, be a just objection to this arrangement, that it throws each of what are commonly called diseases under these different classes, as, in reality, each of the common diseases is more properly three, and exists under three natural classes. Even in this way, does every physician, though unaware of it, consider them, and therefore, instead of giving any new complexity to nosology, it merely explains and simplifies that complexity which ever has existed in the nature of disease. In other words, it is natural, and developes and simplifies only the combinations of nature.

Thus, no one disease, properly so called, can, with the slightest truth, be said to fall under three different classes, as inflammatory and suppurative phthysis, which are even commonly reckoned distinct stages, or as fracture, inflammation, &c. which are essentially different in their nature and may actually be combined in every possible form. Thus it can serve no useful purpose to reckon them one disease, while it destroys every natural arrangement and all the invaluable consequences dependent on it, and absolutely leads first to confusion, next to false reasoning and then to the most fatal errors in actual practice.

Although, however, nosology must thus, in any thing like a natural arrangement, be fixed most accurately upon the basis of physiology, the classification of every disease may be derived from the particular derangement of that individual function which occasions the derangement of all the rest, and not from the derangement of all the three functions which would render names uselessly complex.—I say uselessly, because, as the whole of any one disease, commonly so termed, is primarily dependent on the derangement of one function, so health is to be recovered chiefly by the restoration of that function, and the mode of cure is chiefly indicated by the name of genus under which the disease is primarily arranged. This last is one of the most important consequences of such a system.

If, however, the names of diseases and their classification are not thus made dependent most strictly on each specific change from the healthy state described in physiology, they are at once arbitrary and unnatural; the pathology and nosology of which they constitute a part, have not their foundation in physiology, nor is the practice constructed upon them indicated by the reasonings it delivers.

To reckon a series of occurrences which entirely differ in their nature, consequences and mode of cure, as one disease, may serve the purposes of common language, but by no means those of medical science and medical arrangement.

In considering the natural arrangement of medical science exhibited above, it will be particularly necessary to avoid substituting the term “organ” for “function.” The term “diseases of organs” expresses merely the seats of disease, whilst the term “diseases of functions” expresses their nature. Nevertheless a reference may also be made to the various organs, as it is evident that there may be disease of the vital or any other function in a mechanical organ. Thus a tumour in a bone is a disease of secretion, or an ulcer in a similar situation a disease of absorption; both being orders of the class—Diseases of the vital functions.

The first principle of the medical art, therefore, is founded upon a knowledge of the relations subsisting between the various states of the animal functions and the power of medicines, as exhibited in the preceding sketch of a natural system; and it consists in the application of the articles of the different genera of medicines (exhibited in the last column of the table) to the cure of the corresponding genera of disease (exhibited in the third one).

One of the most beautiful results of the principle I have proposed is, that, by its adoption, it will be possible for the physician to lay his hand upon the several columns of a table, each of which, with regard to the diseases which it enumerates, is precisely similar in its nature from commencement to end; indicates correspondingly arranged articles of the materia medica, and requires precisely a similar mode of cure.

As the same arrangement is applied to the articles of the materia medica, the corresponding medicine will evidently, in every case, readily present itself to him.

But the most signal advantage resulting from it is, that, by merely assigning to any disease its place in nosology, the physician will instantly indicate the mode of cure which ought to be adopted for it.

I shall now then, Gentlemen, conclude by this important remark, that happily the tendency of this natural system of disease is not to controvert one established fact, but, by pointing out their relations, to simplify, consolidate and if possible to increase the amount of our knowledge on all the subjects of medicine.

SECOND PRELIMINARY LECTURE TO THE COURSE OF PATHOLOGY AND THE PRACTICE OF MEDICINE; EXHIBITING A FUNDAMENTAL PRINCIPLE OF SURGICAL OPERATION.

Gentlemen,

The vague plans of Surgical operation, at present practised, are too generally known, and too sincerely deplored, by every man of science and of feeling, to demand much of comment on the present occasion.

How often, in the attempt to take up an artery, does the ignorant and timid operator make an incision so limited that he is afterwards forced cruelly to extend it! How often, having extended his incision, does he find no artery beneath it, and dig or mine for it in a new direction, by cutting up the flesh of the patient! How often, having reached the place he sought for, does he mistake another artery, a nerve, or even a vein, for that which ought to be the subject of operation! How often, having found the artery, is he at a loss to recognize it! What trepidation and alarms does not this operator, more miserable than the patient himself, endure!

I know no situation more wretched or more pitiable than this. Here, even at the best, the most exquisite torture is inflicted: the poor trembling patient, abstracted from every other earthly object, and with the most exquisite feelings concentrated on the present, awaits, in awful suspence, the impending stroke which is to divide the skin, that seat of accumulated sensibility, and deliver him from wretchedness; but the hope is vain, his torments are again and again renewed; he perceives that his life is the sport of a fool; he writhes in agony, or sinks in deliquium; and the issue is, as might be expected, too generally, even at the best, unsuccessful.

When all this is not the case, how often does the operator, on the contrary ignorant and rash, plunge his knife into some vital organ of the patient, and at once terminate his life and his diseases?

That this picture is not too highly coloured, I solemnly appeal to the conscience and the feelings even of the best operators, who are too candid to deny that melancholy reflection has often oppressed them from the fate of patients—martyrs to their want of precision.

To obviate this train of miseries; to give ease and satisfaction to the operator, by conferring precision and success upon his operation, and to rescue from death, or rather from torture and agony, innumerable sufferers, are the results which I confidently expect from the adoption of the following method. Nor can I say more in proof of its importance. I doubt not, that it will, ultimately, constitute the basis and direct the genius of surgery.

There exists no other method of effecting this, than by the enunciation of the following principle; namely, that there is, especially in such parts as are not liable to be deranged by voluntary motion, an invariable relation between the arrangements of internal and the situation of external parts, which may justly be considered as accurate signs of them; in consequence of which, by adopting, on each side of the nerve, artery or other subject of operation, a fixed point, or one rendered fixed by particular positions of the body; and by dividing, according to a line or rule, the space between these fixed points into a given number of proportional parts, i. s. parts, not equally large in all subjects, but uniformly of the same size, with relation to the whole which they compose, and generally differing in the male and female—by these means, I say, the situation of any given subject of operation, in any given part of the body, may be most accurately indicated, as being undeviatingly a certain number of proportional parts distant from the one, and a certain number from the other of these points.

Thus does anatomy, by what I term precise or real proportional measurements between fixed points, afford an obvious and simple, though hitherto unobserved, general means of rendering the operations of surgery perfectly precise and easy.

Indeed, such wonderful precision and ease do these real proportional measurements confer, that, by means of them, the finest instrument may be passed from the surface of the body through any great nerve or vessel that is liable to be the subject of surgical operation.

Having stated this principle, I may merely observe, that, proceeding with all the ease and security, such accuracy must infallibly confer, it is, in all operations the first duty of the operator to ascertain by feeling, as nearly as possible, the thickness of cellular substance situate immediately under the skin of the patient, and then, with a bold and steady hand, to make an incision, deep in proportion to the thickness of that substance, and long in proportion to its depth, as well as to the additional depth and extent of the part to be operated upon.

These general principles excepted, other subordinate rules are chiefly applicable to particular operations.

In order to illustrate this general principle, I cannot adduce a fairer or a better example than that which, according to it, is necessary to direct the taking up of the subclavian artery above the clavicle.

The patient must, in this operation, rest on the fundament, his body slightly inclining backward, so as to form an obtuse angle with the thighs, and his neck and head inclined backward so as to form with the trunk an angle similar to that formed by it with the thighs; the inferior of these angles being concave, the superior convex. This last may indeed be more properly called an irregular segment of a circle, formed in consequence of the vertebrae of the neck bending in that direction. In this position, therefore, the neck is, in general, in the same parallel with the thighs. The head of the patient is to be turned to the opposite side from that in which the operation is to be performed, where also the operator must stand. The light must fall directly downward from the head of the patient.

In this case then, the bringing of the shoulder forward and downward, which I deem indispensible, however necessary to the ease of the operator, is not very material to the correctness of the measurement. It is however of some consequence; for, as the subsequent measurement is dependent on the clavicle, and as that bone describes a portion of a circle in having its lateral end brought forward, every single point of it would, in that position, have a different relation to the vessels beneath from that which each would have had, if kept in its usual position.

Here then, the shoulder being in this position, and the arm held by the side, the measurement commences, and the fixed point chosen on each side of the immediate subject operation are the two ends of the clavicle; as nearly between these as can be done, consistently with keeping quite clear of the bone, a line must be drawn superior and internal to it, and the given number of proportional parts, into which this line must be divided, are seven in number both in the male and female; and now the situation of the artery may be most accurately indicated as being undeviatingly three of these proportional parts distant from the inner, and four from the outer end of the clavicle; in consequence of which, if a fine instrument, held at right angles to the clavicle, were directed downward and inward, it would at 1 and ¼ of the above mentioned parts from the surface of the clavicle, reach the artery, and being pushed farther, would pass through it.

This is an absolute demonstration of the precision and ease attending the principle I have announced, and of its applicability even to the most difficult of all operations.

In order, however, to perform the operation throughout, the point which I have indicated must be the center of an incision through the integuments made in the line above mentioned, and must extend at least two parts inward and two outward from the central point. Over the Trapezius outward, and over the clavicular attachment of the Sterno-cleido-mastoid muscle inward, it is not adviseable to cut deeper than the integuments, which sufficiently relieves the hand of the operator, without the present execrable practice of dividing the last mentioned muscle, which is not only unnecessary, but highly faulty, as this attachment serves as one of those particular points, above alluded to, incidental to certain operations, which, by means of its edge, kept lax during the operation, very nearly directs the knife to a small protuberance on the superior anterior surface of the first rib to which the scalenus primus is attached, and immediately external to which the artery itself lies.

Above all, the incision ought to be cautiously continued on the inner side, in order to avoid the large veins situate there; various branches of these veins may come in the way, and the more considerable may be easily avoided, but if not, they may be tyed.

In continuing the incision inward and downward, an ascending branch of the vein is in the way, which, when it is considerable, may also, previous to the continuance of the incision, be tyed. The incision itself, as you pass inward, must be very limited indeed, as the jugular vein is internal to it; and external to it there is a twig of the brachial nerve, both of which are much exposed to injury.

When the incision has been made one and a fourth of these proportional parts inward from the outside of the clavicle, you have reached the artery. It lays external to that protuberance of the first rib into which, as already observed, the scalenus primus is inserted, and consequently to the insertion of the muscle itself. The twig of the nerve actually crosses the artery immediately below the point where the latter ought to be tyed. The course of the artery is, in descending, obliquely outward, and the precise space in which it lays resembles an isosceles triangle formed by the clavicle, clavicular portion of the sterno-cleido-mastoideus and the omo hyodeus; its base being the clavicular portion of the sterno-cleido-mastoideus. The nerve is external and anterior to the artery, particularly its branch. Both the twig and trunk of the nerve ought to be seen by the operator before he attempt to take up the artery.

These directions are so precise, that, were the operator blind and the artery destitute of pulsation, he need not scruple to take up that which presents itself in the above mentioned situation.

By similar measurements, may every great artery in the body, liable to be the subject of surgical operation, be discovered with similar ease and precision, nor does there exist any other method of effecting this purpose.

I shall now then state the objections which may be urged against this principle.

It may be objected to the adoption of this fundamental principle of all surgical operation.

1st, That the accidental and probable fracture of the bone affording the fixed points, would, by deranging these points, render all such measurement inapplicable.

2d, That varieties in the distribution of arteries, and those deviations which are often produced by disease, would have the same effect.

I know not of any other objection that can be urged against it, and these I shall immediately answer.

1st, To the objection that the accidental and probable fracture of the bone affording the fixed points would, by deranging these points, render all such measurements inapplicable, I answer, that, to chuse as an example the operation I formerly described, it is, in such a case, only necessary to transfer the measurement to the sound clavicle, and to convert the three inner or four outer proportional parts into absolute inches, quantities similar to which may then be measured from the corresponding ends of the fractured one, and thereby indicate the situation of the vessel or nerve with as great precision as if no fracture were involved.

2d, To the objection that varieties in the distribution of arteries, and those deviations which are often produced by disease, would have the same effect, I answer, that variety of distribution does not at all take place in some of those parts in which the most important operations have to be performed; namely, high in the groin, above and below the clavicle, &c. and that, wherever great deviation is caused by disease, it will generally be attended by external signs, according to which the operator may modify his measurements. I also further answer, that wherever deviation, from either of these causes, occurs, he who, by means of these measurements, knows the precise situation, according to the most usual and regular structure, will have the most decided advantage over him who is ignorant of it: the former will possess data, from which he can calculate probable deviations, the latter none; the former, even at the worst, will have to calculate, the latter will be unable to do more than guess.

Thus I have answered the only objections that it is possible to urge against the principle proposed.

I have already said, that private objections by persons who dare not publicly make one, and who themselves cannot, by one or two incisions, approach within several inches of any artery, I shall uniformly despise, and shall only ask them to perform the operation with my youngest pupil.

I shall now deliver a short history of the method proposed.

The want of some guide to the situation of internal parts, has long been felt. Fixed points have been adopted, but with no regularity. Measurements guessed by the eye have sometimes been used, but even they have almost always been absolute, i. s. measurements from one point; rarely proportional, i. s. measurements between two points. The few guessed proportional measurements, however, as for paracentesis abdominis, paracentesis thoracis, &c. which have been mentioned in surgical works, have, it must be confessed, been such as, from the magnitude of the parts with which they were concerned, required little more than guess. Such, however, as they were, they evidently depended upon no principle, but seem as if hit upon accidentally, and, at all events, were never generally applied.

Precise or real proportional measurements between fixed points, applicable to minute objects, i. s. such measurements as I have proposed and described, never have been, as far as I can discover, proposed and described before. And these precise or real proportional measurements, between fixed points, differ exactly as much from guessed ones, as the accurate cabinet, which was regulated in every part by the compass and square, would differ from the clumsy and unserviceable one, where every thing was constructed by guess. Here the parallel is so close, the difference in the results so striking, that I could not have adduced a better illustration.

The present proposition, of precise or real proportional measurements between fixed points, was communicated by me, about five or six years ago, to James Macartney Esq. lecturer on comparative anatomy, and the laws of organic existence, at St. Bartholomew’s Hospital, and, in my opinion, one of the best comparative anatomists in Europe. I had no sooner announced it, than he assured me that a similar method had struck himself; and I deem this, so far as authority goes, no mean testimony in behalf of its value.

Mr Macartney, some time afterward, performed upon the dead subject, in the dissecting room at St. Bartholomew’s, the difficult operation I have just described, according to the direction I have given, and both politely acknowledged me as the proposer, and bestowed on it his approbation. It is my duty to remark, that there is no person whose approbation could give me higher satisfaction.

I cannot better illustrate the danger arising from ignorance of this principle, than by quoting an instance of repeated failure in the very operation above described, in consequence of such ignorance.

A professor at an hospital in London, generally reckoned one of the ablest surgeons of the metropolis, when illustrating this operation in his lectures, first made the usual guessed cut, passing across one half of the Sterno-cleido-mastoid muscle; and, after some tearing and cutting, and innumerable complaints against the knives and the unfortunate assistant, told his pupils, “that they might think he had not yet got the artery, but he knew he had, and he should know it in the living subject, even if it did not pulsate.” The subject, however, was carried from the lecture-room, and the ligature was found to be firmly fixed upon the nerve.

This mistake was very properly communicated to the ingenious surgeon, who never forgave the discoverer of it, but very wisely planned how he might avoid the same mistake, or, what he seemed to dread most, its consequences to his own reputation, in the subsequent course.

He had thus found, that ligatures left in the dead subject were more troublesome than in the living; and having tied something, which, to judge from the vague way in which he described it, might be a muscle as readily as an artery, he very properly, as his mind was not quite made up upon the subject, secured, to all appearance, his well earned fame, by cutting off and withdrawing the ligature that nobody might see what he had done.

Unfortunately, however, curiosity and the wonder that it was possible for so great a surgeon to make so deplorable and dangerous an error, prompted a second examination of the subject. No ligature now remained to direct the enquirer’s search; but alas! artifice could not obtain impunity even to reputation—the artery remained bedded in fat and untouched, the nerve alone was separated from the mass, and bore the mark of the ligature.

May the relation of these disgraceful occurrences, selected from numerous similar ones, which, to my knowledge, have taken place both in London and Edinburgh; but which, as, fortunately for their authors, they produce no injury to reputation, I am therefore unwilling to state—may it, I say, serve as a proof of the danger arising from ignorance of the principle I have proposed.

Now, may I ask, what are we to think of the supporters—the promulgators of such doctrines, and the abettors of their authors? Such men are to be found in Edinburgh, as well as in London.

Suppose, for a moment, one of these gentlemen, who are the deriders of precise and accurate methods, proposing to perform on the dead subject, in the most fascinating and splendid style, the operation for tying the femoral artery. He delivers a proem which shall verbally assure the pupil of its ease, but, by the complex flourishes of his knife, he intends to convince him it is difficult. He expects, however, that he shall speedily lay it bare, and that his dexterity, in the midst of such complexity, will produce the most brilliant effect. But alas! his first incision is made about an inch from the artery—still he cuts deep, in order to discover it—now he is embarrassed at his situation—next he mines off laterally, forms excavations under the flesh, and leaves the artery above the course of his incision—at last he reaches the profound, instead of the superficial artery, and comes off with the never-failing, and, in this case, ridiculous excuse, that there was an unusual distribution of it.... The errors of Surgeons have very curiously discovered a greater number of varieties in the distribution of arteries than ever were demonstrated by the labours of anatomists.

I have seen one of these surgeons commence such a disgraceful operation with more flourishes of the knife, than ever a dragoon used when performing the Saxon exercise with the sabre. Contrast this with the plain and manly operator, every movement of whose knife has a meaning, because every movement of it is strictly adapted to effect the most useful of purposes.⁠[1]⁠

I have now only to add a few words concerning the necessity of such precise methods of operation in the present military state of Europe.

While such important operations remain in so vague a state, what ease would not such measurements confer, when, in the cockpit of the man of war or on the field of battle, the perplexed and bewildered surgeon knows not where to turn him, but must leave an hundred operations in an hour to an unexperienced assistant.

At a time, when a successful conspiracy of adventurous ruffians are, at the point of the bayonet, establishing, from the Don to the Douro, from the Scheldt to the Cattarro, over all the fairest provinces of Europe, the most dreadful of military despotisms;—at a time, when, to the shout “Avance, Avance,” louder and more tremendous than the noise of their guns, the myriad legions of France are carrying death and destruction before them, and sweeping together man and civilization from the face of the Continent;—at a time, when he who has “sceptres tipt with coronets for his pallisadoes, kingdoms for his martello towers and kings for his centinels,” threats at once the liberties and the existence of Britain, and stains every step of his career with perfidy and blood;—at a time, when it is the duty—it is the wish of every man of honour successfully to defend, or, covered with wounds, nobly to die for the liberties of Britain and the emancipation of Europe—when all this is the case, what are not his duties whose sole profession it is, aided by science, to rescue from death or agony those whom tyranny has attempted to destroy, the genius of whose god-like art it is to save both friends and foes; and, upon whose knowledge, the existence and the fate of armies may, in no small degree, be said to depend.

Never were the duties of the military surgeon more complex or more formidable. Never did he stand in need of greater precision. And, in his art at least, he ought to recollect that no commissions are sold—the precisest knowledge alone entitles to—infallibly secures, pre-eminence and fortune.

POSTSCRIPT.

Since the publication of my Prospectus, and of the observations delivered in the previous note, the persons to whom that note alludes, have become ashamed of their conduct, and have, both in their lectures and through the press, asserted that I was not the object of their public attack; but that, although it was quite unconnected with the object of the pamphlet in which it appeared, yet they had taken the trouble to direct the attack against a gentleman at almost a thousand miles distance from them, and only two copies of whose book had ever reached the country; because, I suppose, they were alarmed lest, at that short distance, that gentleman should influence attendance upon their lectures, and lest a work so widely diffused over the country should “encourage the rash and the ignorant to sport, by means of accurate measurements, with the lives of their fellow creatures, and entail disgrace and misery on themselves....” Humanity is certainly deeply indebted to their generous, disinterested and philanthropic exertions! How much to be regretted that it has not ever had such guardians! Monuments doubtless, rivalling that of the hero of Trafalgar, will be erected to their memory—monuments of a nobler kind, because destined to record, not the triumphs of war, but the triumphs of lectureship in anatomy, physiology and surgery, which certainly involve, not the destruction, but the preservation of lives.

What! M. Richerand, only at a thousand miles distance, influencing the newly organized courses of lectures in Edinburgh, and two copies of his dangerous book, proposing precise measurements in surgery, actually in the British empire.—Some gentlemen, perhaps, may be sufficiently ill-informed to imagine that the attack was really directed against so weak a creature as myself. How improbable! It is self-evident that I, in Edinburgh, could not have a thousandth part of the influence upon their lectures, that M. Richerand could at the distance of a thousand miles, and that my lectures, inculcating the principle every day, could not have a millionth part of the tendency to “encourage the rash and ignorant to sport, by means of accurate measurements, with the lives of their fellow creatures and entail disgrace and misery on themselves,” that two copies of M. Richerand’s book, actually in the country, must infallibly have.... He would be almost mad who could suppose the allusion was to me, because I was at hand and therefore could have no influence upon their lectures; I was delivering these opinions every day, and they therefore could not be disseminated: hence these gentlemen had no earthly interest in alluding to me. He, on the contrary, is wise who supposes that the allusion is to M. Richerand, because he is in Paris and therefore must have great influence upon their lectures; of his book even two copies are in the British empire and its sentiments consequently must be most widely disseminated; and it was well contrived and inexpressibly humane to introduce and firmly to oppose such a desperate character, even in a work upon a different subject. In short, these gentlemen had the nearest interest in opposing him.... Well, it must certainly be highly satisfactory to have thus opposed the progress of error and rescued the human race from disgrace and misery. Generous, disinterested, philanthropic defenders of humanity, you have your reward in your own breasts.

But their apology will not bear the test of ridicule. Let us therefore examine, in another way, the foundation upon which it rests.

After denying the truth of the principle they ascribe it to another. And who is ignorant that this has been the fate of every original proposition? M. Richerand, they say, discovered it in 1805. Now granting, for a moment, the truth of this, I preceded him by a year or two at least, and James Macartney, Esq. lecturer on comparative anatomy, even constructed, twelve months before the time they mention, a work upon the principle, for which he was favoured with drawings by Charles Bell, Esq. at the time the discovery is ascribed to M. Richerand. I mention these facts because, even granting the truth of what these gentlemen state, it refutes the assertions they found upon it.—I shall make a point of laying the further details on this subject (to me very important) before the medical world, which will show that, even since I first enunciated the principle, neither M. Richerand, nor any other person, has even repeated the proposition, and I defy these gentlemen to produce an instance of it. This, however, I must remark, even these gentlemen most inconsistently grant; for they say that the proposal, which they assert was made by M. Richerand, has been tried and has failed; whereas the proposition enunciated by me has been tried, has uniformly succeeded, and, such is its correctness, that it constitutes the basis of that part of my course which involves the operations of surgery. Therefore, even according to themselves, the propositions cannot be the same.

I may now conclude by observing, that, notwithstanding the conduct of these gentlemen, I am far from bearing them any personal dislike,—but shall, on the contrary, be happy to labour with them in the same vineyard, and wish them the utmost success.

Mr Walker’s Course of Anatomy and Physiology recommences on Tuesday the 8th of November, at eleven o’clock, a. m. and his Course of Pathology and the Practice of Medicine, at two o’clock, p. m. and will be continued daily at these hours, at No. 63, SOUTH BRIDGE-STREET.