VINCENT'S OBSERVATIONS ON SURGICAL PRACTICE.
Irt this volume the late Senior Surgeon of St. Bartholomew's Hospital has propounded a view, in "a Preliminary Inquiry into the claims that Surgery may be supposed to have for being classed as a Science "; and given to the world the results of a professional life of observation, ex- perience, and reflection, in the "Observations on Some Parts of Surgical Practice." The endeavour to raise surgery to the rank of the sciences, seems to have originated in an idea of Mr. Vincent as to the utility and indeed necessity of studying the centre of gravity in the human body, and the principles of mechanical science as they are exhibited in the bones and muscles, with a view to apply those principles in the case of fractured or dislocated limbs. And thus far, no doubt, surgery might be ranked as a physical science. To set bones or replace joints, how- ever, is only one part of surgery. Operations are as conspicuous, and perhaps a more important branch of the profession; but these depend for general success upon qualities that cannot be acquired from study alone. As a mere matter of performance, an operation is no doubt some- thing like a mathematical question ; but such a view degrades the sur- geon to a mechanical craftsman. The most important question, as to whether the operation should be undertaken, and when, is a matter of wide inference, dependant upon the character of the injury or disease, the natural constitution of the patient, his previous habits, and present state : the conclusions drawn from these things depend upon experience and the natural abilities of the practitioner, and belong more to art than to science. In like manner, disorder incident to injury, whether natural or from violence, is now and has been for years the legitimate business of the surgeon; and though generally more certain than" physicians' cases," the cause is often obscure enough to be matter of induction ; the proper treatment still more frequently. And here again experience and natural ability will surpass all theoretical acquirement, though eateris paribus the greater the knowledge the better the practice. Hence, surgery perhaps calinardly aspire to a rank among the sciences, except in the lesser sense in which we speak-21 the science of war, law, navigation, and other pur- suits; since in science, strictly speaking, mathematical demonstration should predominate over logical induction. But though surgery may not become a strict science, there is no question about the importance of surgeons acquiring the scientific mind; in which, from a more narrow education and an earlier commencement of professional study, they have been as a body perhaps inferior to physicians. In this point of view Mr. Vincent's essay may be useful, though rather for incidental remarks than for its general arguments ; and the treatment is somewhat formal.
But the great feature of the volume, and by far the most valuable por- tion, is the "Observations on some Parts of Surgical Practice." These Observations are not intended as an exposition of the elements or prin- ciples of surgery; nor are they addressed to the tyro, but to the prac- titioner, or the advanced student about to become a practitioner. Formal classification there is none ; but the Observations extend to the three branches of surgery we have already indicated,—first, fractures and dis- locations; second, operations; third, the disorders which, originating in injuries of violence or natural lesion, come under the surgeon's care : and this order is followed in Mr. Vincent's arrangement, or rather sequence. In the treatment of his subjects two novelties strike us,—the more distinct application of the principles of mechanical philosophy to the re- daction of broken bones and dislocated joints; and the effects of what the author calls the conservative powers of nature to preserve the due ministration [performance?] of functions, even in opposition to mechanical obstacles or physical laws. Many of the illustrative cases he quotes under both these heads are very curious, but are generally of too professional a kind for a popular journal. The true value of the book, however, does not consist in novelties, so much as in the exhibited results of the author's experience, and the prin- ciples of a sound and natural practice which the Observations develop. Simple as the treatment both in medicine and surgery has been gradually becoming, Mr. Vincent advocates a treatment still simpler in many cases; but (and here is the great distinction between the master of his craft and the mere tyro or pretender) with a thorough knowledge of when he should do nothing, and when he should act vigorously, though to common eyes be may seem to be doing contrary to what he ought. The following is an instance of what we mean. The author is speaking of the treatment fol- lowing severe injuries according to the constitutional symptoms the patient displays, and whether Nature may be left to herself or requires aid.
"In all injuries, taking along with us the quality of the injury, we may assume that the vivacity of the excitement caused by the local disturbance is a measure of the vigour of the constitution. But in proportion to the vigour of the consti- tution, so is the power of resisting the changes which local disturbances can effect upon the whole. The vigorous system will be excited into more active exertions, because it has a quicker and a steadier power for effecting readjustment But if, on the other hand, the constitution does not respond with vigour, the vital energy being too low to exert necessary action, and to resist the first invasion, it will probably be powerless to fulfil all the purposes of restoration. These are principles in surgical practice to be borne in mind in settling the points whether a patient with compound fracture is or is not to be bled; whether cases of very great in. juries to the limbs do or do not require amputation upon the instant, &c. "In these grave cases an imperative duty devolves upon the surgeon: he has to detect, if possible, the character of the constitution; he has to scrutinize the pa- tient's pulse, not only on the first moment of the injury, but almost every hour, at least at short intervals, to decide its state, and then to decide whether there is ac- tion sufficient for the purposes of the coming demands. What he has to wish for and to expect is, that there should be some expression of what is called sympa- thetic fever. This 113 really a state that we know indicates a vigorous constitu- tion, and one which will, when subdued into tranquillity, best throw out its power for repairing an injury: and so far from being that fever which has been placed as a fearful object in the scene, it is really a hopeful event in the first three days of an injury; because it assures us of the powerful coadjutor we shall have in all the processes that are to ensue for the benefit of the patient. It is the absence of this excited state in the circulation that should alarm the surgeon: it is the weak, the fluttering, unsteady pulse that should impress him with danger, and raise in him the fear that he may expect gangrene or other miseries that may afflict his patient. "In all serious injuries the constitution is invaded in proportion to the maga- nide of the injury; but the way in which the constitution may meet this invasion is widely different according to its state. The one presents a ready front, and en- courages a hopeful result; another displays its weakness, and calls for the most watchful care. The circumstances that imply health in a general sense are tran- quillity of the nervous and of the circulating systems. To produce this state, the secretions mast be natural: these functions being deranged, the digestive powers are impaired, and nourishment does not go on. If the vigour of the constitution is so defective as not to be roused to an excited movement, in order to sustain, and then to raise and adjust its forces for bringing out the new functions of repara- tion, it must sink under the derangement. It is thus that the surgeon has irn- rosed upon him the greatest responsibility in watching his patient for the first three days after serious injuries, where wounds are inflicted. If in twelve hours, or earlier, the pulse does not indicate increased action—if it becomes fluttering and unequal—when the surface does not seem to evolve heat—when the countenance is listless, and perhaps when the patient reports himself better than it might be ex- pected—and particularly if he is not clear in his answers, but is wavering—then that best of all stimuli, brandy, is to be thrown in, and if there be delirium, opium. The necessity of actual nutriment must not be forgotten. This method must be pursued and moderated as the indications point out, until that period arrives which is the great proof that tranquillity and orderly processes are commencing —suppuration. This process is the striking index that the functions are assum- log an appropriate arrangement for reparation, and that the system is resuming that tranquillity by which the restoration will be carried on to completion."
Some of the most curious instances of the restorative powers of Na- ture and of the manner in which vital functions go on in despite of mechanical and merely physical laws, relate to subjects not well adapted to our columns. The following are curious examples of the curative power, and may furnish hints.
" We see such exquisite adaptation in the lachrymal appendages, that the exercise of their functions is carried on without exciting the least sensation. If a particle of dust be blown upon the eye, which particle is of form and size to
give the sensation of its presence under the lid, and the eyelids be not robbed,then, although it may give pain, this soon goes off, and the patient is no longer aware of its presence. The particle has lodged under the tarsal edge, and be- coming quickly enveloped with the secretion of the glands there, is no longer an irritant, nor does it excite any feeling. It is, indeed, in the condition of the na- tural secretions of the part, and therefore it may be present without impressing the sensations. But nevertheless it is a stimulus, although insensibly so to the part, to excite that process which quietly removes the particle from under the lid, and completely ejects it. "But in the same case if the eye be rubbed, then the particle, instead of re- maining at the edge of the lid and getting a coat of mucus quickly, so as to be quietly removed, is, by the act of rubbing, which excites the orhicularis to retain it, carried further under the lid; where it not only excites a painful sensation, but keeps up the irritation it produces a considerable time; indeed, until it is clothed with mucus, which is now a longer process to go through than in the other case. But here again, when the particle is so coated all pain ceases, and it remains un- felt till it is expelled. These cases are both instances of the stimulus acting,
with a little difference, as stimuli for relief. •
" I have seen a portion of the ear of barley slip into the nostril with the stalk- end foremost. Of course the least touch of a body so formed, in such a situation, mast add to its further intrusion. It produced considerable irritation for a day or two, which then went off; and quickly after it came quietly away, coated with thick mucus, without any effort. This short history explains the practice to be enjoined; which is, indeed, negative, as in the case of the particle under the eye- lid. The irritation it set up was to establish a new conservative function; it was to clothe it with a thick adhesive mucus, more substantial than the common se- cretion of the part; yet still it was mucus, that it might exist as a secretion to which the structure is adapted, and on which it might act simply as a stimulus for its expulsion, the excitement being just sufficient for the purpose. It passes out in the quietest way, not even causing sneezing, or any effort of the patient. This explanation of the course Nature adopts under such circumstances points out the line of treatment the surgeon is to follow; which is, indeed, negative. He is not to injure the part with his forceps by unnecessarily repeating attempts to ex- tract it; he is not to allow of any effort of sneezing or blowing the nose, with the intention of its passing off in this way. He is to require that the patient should be very quiet, that the substance may be kept in one situation, so as to acquire the coating as soon as possible, by which means the substance will be soonest ejected. "I have seen a case where a small piece of a leaf of a vegetable had got into the ventricle of the glottis: it caused very much irritation and coughing for some hours; but it was soon enveloped with mucus, and came quietly away the next day. It has never happened to me to have a case of a foreign body in the tra- chea. but should such a patient come under my management, I should not think of milking an opening into the trachea to extract it, provided it was under one condition, that is, that it moved up and down in the tube. Recorded cases have proved that this operation is not necessary. But I should not only reverse the present practice in this point but in others. My purpose would be to get the fo- reign body clothed with mucus as soon as possible. To attain this, it requires that the body be kept stationary: and to insure this as much as possible, the pa- tient should be kept in bed or perfectly quiet; he should avoid all effort to expec- torate; and very soon, I have no doubt, the body would easily pass off. I have further to notice, that in this case we have evidence that the functions of life often oppose the principles of statics; furl infer that the foreign body'would be less likely to pass out if the patient was placed with his heels upwards than when he was sitting. up; because the process of expectoration is a function most easily carried on in the erect position of the body.
The principle advocated in the following passage must be "used as not abusing it." The surgeon, it should be remembered, is speaking of cases where complete rest is necessary to restoration.
"There is necessity in ordinary states for the observance of repose, in order that the full and equable powers of reparation may be developed; and as this often necessarily infers the repose of the whole body, I must advert to what is the con- sequence of this state being implicitly complied with It seems an accepted opi- nion, not only of the great mass of people but of the bulk of the profession, that remaining in bed destroys health: but the value of this opinion must be placed in its trite light. If health mean the mere muscular power in the usual exercises of the body when free to move, then some countenance may be allowed to this opi- nion. Certainly the muscular subject cannot vault into his saddle, or throw the quoit, after being kept to his bed, as otherwise he would have been able to do. But if health mean the orderly exercise and equable succession of those functions of which life is made up, then I have reason for thinking that with some precau- tions health is very well maintained in bed. I have often known patients to have been in bed not only months but even years, and I have observed that all those pro- cesses which present themselves as marks of health are present. I have seen pa- tients, after having been in bed sometime, enjoy their food with an appetite to which they had been unaccustomed; sleep unaided by sedatives in a more than usually composed manner; the natural relief of the bowels being regular, and the skin per- forming its functions uninterruptedly. In short, these patients have been in the very best state for the agencies to repair imperceptibly the disturbances from injuries and other causes. Without the repose of bed, the surgeon often would idle away his time, waste his resources, and inflict suffering upon his patient in the greater number or his case.. „The prejudice against this treatment has arisen from the fact that patients are generelly sent to bed with a wasting disease upon them; sad when the period of convalescPnce approaches, they attribute to bed that weakness and debility which is the conzeguence of the complaint for which they were consigned to it."
Mr. Vincent's Observations are close and weighty, from the reality and fulness of his matter : his style is rather formal, and shows occasion- ally, in unfinished sentences and similar minutim, marks of a man ap- parently not accustomed to composition, though well able to express himself. The character of the book, however, is not literary. Its value arises from containing the essence of a skilful and original-minded man's professional experience, acquired in one of the first schools in this country.
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