"l'art (de délicatesse) consiste à ne pas tout dire sur certains sujets, à glisser dessus plut?t que d'y appuyer; en un mot, à en laisser penser aux autres plut?t que l'on n'en dit."—bouhours.
one of the most beautiful poems in the english language, perhaps, is armstrong's "art of health." whether it be that the title is uninviting, or from some other cause, i know not, but it is very little read; yet scarcely any one who has read it, has done so without pleasure. besides containing many admirable and valuable instructions, it shows how an ordinary, and to many even a repulsive, subject can be treated with such discretion, taste, and even elegance, as to render it pleasing and attractive.
such a writer could have conveyed, even in prose, explanations of disease so as to interest and instruct his readers. with no such power, we are almost inclined to regret the impossibility of doing abernethy justice, without saying something of nearly all his works. if, however, in so doing, we make one more step towards familiarizing the public with matters which affect their best interests, we shall not regret any labour which this, the most difficult part of our task, may have required.
we so usually connect pain with disease, that, in our haste, we are apt to imagine that it is not merely the worst feature, but the only sign of it. "i am very well, i am in no pain whatever," is a common expression, and yet a person may be irremediably stricken, without suffering any pain. pain is, in fact, often the best possible monitor, and has saved many thousands of lives by the necessity it has imposed of observing what is the best of all remedies, in a large class of cases. amongst hundreds of examples,56 we might cite several affections of joints, wherein pain alone has sometimes exacted the observance of that which surgeons were a long time before they had learned the full advantage of; and which, when they had been taught it by abernethy, they have often failed, with all their endeavours, to accomplish, but which, when efficiently secured, is of more consequence than any one other remedy; we mean "absolute repose" there are plenty of diseases marked by little or no pain, or which, at all events, are not painful; but they are amongst the most fatal and insidious of human maladies. let us commence the record of some of the numerous improvements we owe to the genius of abernethy, by mentioning one of them.
we have, too many of us probably, observed something like the following, on the assembling of a family of a morning: the usual greetings interchanged, and that cheerful meal, breakfast, fairly begun, our attention has been directed to some fine, comely, perhaps beautiful girl, who, to the hilarious spirits of her laughing sisters, has only contributed a somewhat languid smile. we may, perhaps, have remarked that she is a little more spoken to by her mother than any other of the family circle; we may, too, have observed a tone compounded of confidence and gentleness, somewhat different from that addressed to her sisters. still, though less hilarious than the rest, she has chatted away with considerable cheerfulness; she has, however, a languor in her manner, which but for the surrounding contrast, might not have occurred to us. on rising from the breakfast-table, we observe that her gait is peculiar. she is not exactly lame; but her step has something between firmness and faltering, that seems to indicate more effort or less power.
poor girl! she is about to have, if she have it not already, a stealthy and hitherto almost painless disease; stealthy, because it is so far a comparatively painless malady. deep in the loins there has been the smouldering fire of disease, which is to result in what is called "lumbar abscess." this grievous malady, which in many instances begins not less insidiously than i have mentioned, is found on inquiry not to have been wholly without some of those premonitory signs which, in obedience to the beneficent57 laws of the animal economy, almost invariably precede even the most insidious malady. inquiry generally elicits that, however little complained of, there has been at times more or less of uneasiness, if not pain, felt in the loins; that it has not been so much lately; but that it has become less in force or frequency, since the appearance of some swelling, which may be in the loins, or some other part, lower or more or less distant.
it is a malady very commonly connected with diseased spine, but frequently without any such complication; and it is curious that mr. abernethy at first met with as many as, i think, eight cases in succession, which were not complicated with any disease of the spine. under any circumstances, it is a serious malady, and usually, when the collection bursts, or is opened, severe constitutional symptoms supervene, which, though not without exceptions, gradually usher in what armstrong calls
"the slow minings of the hectic fire,"
and destroy the patient.
now, mr. abernethy's plan was intended to prevent this last and dreaded issue. the chief points of excellence in his recommendations are—
first, the emphatic recognition of the constitutional origin and nature of the malady;
secondly, the consequent necessity of a greater attention to the general health of the patient;
and lastly, if it could not be dispersed, to relieve the interior of its contents, so that its extensive surface should never be exposed.
the mode of proceeding was extremely simple, and there is no doubt that a great many lives have been saved by the practice thus recommended. i have heard, however, that some surgeons think the merits of the plan overrated, which i can only suppose explicable on the ground that it has been imperfectly followed out; and i am the more disposed to this view, because nothing can be more entirely opposed to mr. abernethy's principles and intentions, than the treatment of many cases said to have been treated after mr. abernethy's plan.
58
as a considerable number of families have really a painful interest in this question, i will, at the risk of being a little professional, state what has occurred under my own observation, in explanation of the apparent discrepancy. my own experience obliges me to coincide with those authorities on this subject, who, approving mr. abernethy's practice, adopted it. amongst a host of eminent men, i will mention only two, sir astley cooper, and a scarcely less eminent authority, mr. samuel cooper, the laborious and distinguished author of the "surgical dictionary," who observes that mr. abernethy's plan deserves "infinite praise." sir astley cooper, too, in speaking of a very dangerous period of the case to which mr. abernethy's plan has an important relation, says: "we should adopt the plan suggested by mr. abernethy, as it is the best ever invented by any surgeon." the apparent discrepancy in the results of the experience of different surgeons, is rather a matter of degree, and admits of easy explanation.
the feature whence the disease derives its name is merely a partial exposition of an exceedingly deranged state of the whole economy, not unfrequently complicated with organic disease. although mr. abernethy's paper shows that even these cases are not necessarily fatal, still, in general, such will sooner or later terminate unfavourably under any treatment; but, in many others, the explanation which i first suggested has been a satisfactory solution of the failure: viz. that the principle on which abernethy proceeded has not been seized, and that therefore the treatment has involved direct violations of it. in some, the local relief has been by no means conducted with the observance of those conditions which mr. abernethy has enjoined. in others, there has not been even any reasonable approximation to that careful attention to the general health which is the necessary basis of the plan.
another point, which has in some cases impeded the adoption of the practice, is the increased responsibility it seems to involve. if a surgeon is to be mistrusted and charged with either, the "laisser mourir" is much less injurious to him than the "tuer." what we mean is this: everything sometimes is going on well, until the opening of the deposited fluid. if it be left to open by59 the ordinary processes of nature, the subsequent symptoms are properly enough ascribed to the usual course of the disease; but if the surgeon has interfered, and, from any circumstances whatever, the opening does not heal, or bursts soon after from some slight accident (which has now and then happened), the surgeon is blamed. the only remedy for this, is to impress the necessary caution: repose of the part, and so forth.
there is, however, a third point, of great practical consequence, on which mr. abernethy has been misunderstood. i allude to the local condition under which the puncture should be made. when, notwithstanding our persevering observance of all measures calculated to repress the diseased actions, or to procure the absorption of the deposited fluid, we perceive it to be increasing or approaching the surface, then, before any inflammation of the skin has taken place, it should be discharged.
in many cases, this opening has been delayed until the skin has become inflamed, or much attenuated. now this risks the accomplishment of an object which it is a material point with mr. abernethy to secure—namely, the immediate healing of the puncture.
on this point, even so good an authority as sir astley cooper has given a misdirection. "let the abscess proceed," says sir astley, "until you observe a blush or redness on the skin, and then adopt mr. abernethy's plan." now this direction does not absolutely prohibit the opening of the cyst with the object which mr. abernethy had in view; but, as before stated, it deprives us of one most desirable condition. to settle this point, we quote mr. abernethy's own words. in discussing the point of time at which the opening should be made, he asks: "are we to wait until evident signs of inflammation appear? i think not." accordingly, in a case where the surface had become red, we find he took care to avoid opening it at that part; because it risked the security of at once healing the puncture.
the truth is, that the whole of the plan is most valuable; but it must be carefully followed in its integrity; and that this may be done, the principles on which it is founded must be constantly kept in mind. these are—the improvement of the general health,60 with the view of arresting the action of disease, and producing the absorption of the morbid secretion. this failing, to puncture the abscess, so as to secure the discharge of its contents without the admission of air, and on conditions calculated to ensure the immediate healing of the wound; then to favour the approximation of the sides of the cavity, by relieving it of its contents, by puncturing it anew, before it shall have become so much distended.
another misapprehension has arisen with regard to mr. abernethy's object in excluding air; and unnecessary pains have been taken to show that the presence of air is not injurious to living surfaces. it was not from any apprehension of this kind that he was anxious to exclude the air; but from the tendency that the presence of air had to favour the putrefactive decomposition of the new secretion. we must not omit to mention the origin of this instructive paper, as it is highly characteristic of abernethy's acuteness of observation, and his promptitude in the practical application of it.
a lumbar abscess had been opened by caustic, and when the eschar had nearly separated, the cyst was partly emptied; the sides of the cavity collapsing on the imperfectly separated eschar, the opening was closed, and none of the usual constitutional disturbance followed. when, however, the eschar, finally separating, exposed the cyst,—within twelve hours, the usual dreaded disturbance of the system supervened. abernethy took the hint thus disclosed to him, and produced the improvement, of the merits of which we have endeavoured to give a brief representation.
