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.