THE UNIVERSITY OF ILLINOIS LIBRARY ■/K \ f \ y THE SCIENCE AND ART SURGERY. BEING A TREATISE SURGICAL INJURIES, DISEASES, AND OPERATIONS. BY JOH^^ EEIC ERICHSE]^', SENIOR SURGEON TO UNIVERSITY COLLEGE HOSPITAL, AND HOLME PROFESSOR OF CLINICAL SURGERY IN UNIVERSITY COLLEGE, LONDON. t A NEW EDITION, ENLARGED AND CAREFULLY REVISED BY THE AUTHOR. Illustrateb bg itpbarbs of ^eben ^unbreb ^ngrabings on Siloob. VOL. 1. PHILADELPHIA: HEI^RY C. LEA. 1873 .“ “ They he the best Chirurgeons which being learned incline to the traditions of experience^ or being empirics incline to the methods of learning.'''' Bacon on Learning. % PHILADELPHIA S ' COLLINS, PRINTER, 705 JAYNE STREET. Z Ir ■ V I ■ K-t-^S6 ■ II . ■I i i r. i PEEFACE J TO THE ](EW AMERICA?^ EDITIOJf. i _ 1 i The favorable reception with which the Science and Art of Surgerf’ has been honored bj the Surgical Profession in the LTnited States of America, has not only been a source of deep gratification and of just pride to me, but has laid the foundation of many professional friendships that are amongst the most agree¬ able and valued recollections of my life. I have endeavored to make the present Edition of this work more deserving than its predecessors of the favor that has been accorded to them. In consecpience of delays that have unavoida¬ bly occurred in the publication of the 6th British Edition, time has been afiPorded me to add to this one several paragraphs which I trust will be found to increase the practical value of the work. London, October, 1872. JOHX ERIC ERICHSEX. PREFACE TO THE SIXTH EXGLISH EDITIOX. Every effort has been made to render the “ Science and Art of Suro’ery” in its Sixth Edition worthy of that confidence with O %j t/ which the Profession has so long favored it, as a Guide to the Practitioner and a Text-Book for the Student in Surgery. And although little more than three years has passed since the publica¬ tion of the last Edition, it has been found necessary, in order to enable the present one to keep abreast of the general advance of Surgical Science and Practice, to make considerable changes in tlie work, by which I trust it will be found to have been correspond¬ ingly improved. Notwithstanding every desire to prevent any unnecessary in¬ crease in the size of the Volumes, in has been found impossible to keep them within the limits even of the last Edition, and a considerable addition to the text has been rendered unavoidable, although much matter that was somewhat obsolete has been struck out. Several chapters have been recast, and some almost rewritten. The alterations and additions thus made have not been confined to any one part of the Wrk, but have been very generally dis¬ tributed through the x'arious subjects of which it treats. Many of the wood-cuts have been redrawn, and nearly a hun¬ dred new illustrations have been added. Mr. Streatfeild has again most kindly given me his valuable assistance in bringing up his Chapter on Ophthalmic Surgery to VI PREFACE. the standard of modern requirements, and has thus added greatly to the value and-utility of the Work. To my friends and former pupils, Messrs. Kiallmark and Beck, I am indebted for much valuable assistance in the preparation of this Edition: to Mr Kiallmark for the aid he has o-iveii me in the o earlier ftarts of the first volume, and to Mr. Beck for that which he has rendered me throughout the Work. To Dr. A. Henrv I am again indebted, as I have been in several former Editions, for materially lightening the literary labor that would otherwise have devolved on me in carrying this one through the press, and for several most useful suggestions in connection with its arrangement. I can but hope that the present Edition of the “ Science and Art of Surgery ” will be found to deserve the same favorable reception that the preceding ones have met with from Surgeons and Pupils in this country, the Colonies, the United States of America, and many parts of the Continent of Europe. JOHX EKIC EEICHSEX. 6, Cavendish Place, London, W., October., 1872. NOTE. The Science and Art of Surgery constitutes that great Depart¬ ment of Medicine in its widest acceptation, which comprises the consideration of— 1. Injuries —from whatever cause arising—and whatever part affecting—to which the human frame is liable—their IN'ature —mode of Repair and Treatment. 2. Malformations and Deformities —Congenital and Acquired. 3. External Diseases —and all those Diseases that specially or primarily affect the Organs of Sense, of Locomotion, and of Reproduction in both Sexes. 4. Diseases that are the direct consequences of Injury. 5. Diseases that require Manual, Mechanical, or Operative means , for their cure and relief. 6. Operations of whatever kind that are required for the Cure, Removal, or Relief of any of the above Conditions or Diseases. For the consideration of these various subjects, this Work is di¬ vided into three parts: The First —under the head of General Principles —contains general observations on Operative Surgery, more especially on Am¬ putations, and a condensed view of the Hature and Treatment of Inhammation from a Surgical aspect. The Second Division comprises the considelation of Surgical Injuries. The Third contains that of Surgical Diseases. In considering both Injuries and Diseases^ the following arrange¬ ment has been adopted:— 1. Those common to all Parts of the Body. As in Injuries— Wounds. In Diseases—Erysipelas—Tumors. 2. Those affecting Special Tissues. As in Injuries—Fractures of Bones and Wounds of Bloodvessels. In Diseases—Caries, R’ecrosis, and Aneurism. 3. Those affecting respectively different Regions of the Body— as the Head, Chest, or Abdomen. Vlll NOTE. In treating of tliese various subjects, the descriptions that are given of tlie Symptoms, Causes, Diagnosis, and Treatment, are as full as the importance of each demands, and the present state of knowledge permits. But as a full examination of the important researches made in recent years in Pathology would not be possible in a work intended principally to teach the Practice of Surgery, this subject is introduced to a sufficient extent only to place before the student a summary of the most approved observations, espe¬ cially those which are likely to be of clinical or practical value. Diagnosis receives special attention; and, as accuracy in this is an all-important requisite for success in Treatment, the conditions with which each injury or disease may be confounded are carefully de¬ scribed, and the means of distinguishing one from another pointed out. Throughout the'Work, the object is to place before the prac¬ titioner and student the Science and Art of Surgery, not as consist¬ ing merely in the observation of such Diseases, Injuries, and Mal¬ formations as belong to the classes mentioned above, or in the dex¬ terous application of manual or operative means for their relief; but as demanding an exercise of general Medical knowledge, and a thorough acquaintance with all those conditions, whether intrinsic to the patient or surrounding him, that favor or prevent his restora¬ tion to health. ' . J. E. E. CONTEXTS OF THE FIRST VOLUME. DIVISIOX FIRST. FIRST PRINCIPLES. Chapter I.—General Considerations on Operations. PAGE Objects of Surgical Operations—N ature of Knowledge required—Condi¬ tions Influencing Success of Operations—Causes of Danger and Death— Preparations for Operation.—A naesthetics—C hloroform—Its A\dministra- tion—Secondaiy Effects—Death from Chloroform—Ether—Nitrous OA^ide— Bichloride of Methylene—Treatment of Eflect of Over-dose of Anresthetics —Local Anaesthesia.—O peRaATIon—I ncisions—Sutures—Dressing—A^fter- Treatment.17-40 Chapter II.—Amput.attons and DiSaARTicuLaAtions. Amputations—P revention of Hemorrhage—Modes of Amputating—Flap AA.mputation—Instruments—Double Flaps—Rectangular Flaps—Long Flap —Sawing the Bone—A^rrest of Hemorrhage—Dressings—A^ccidents in Heal¬ ing of Stump—Simultaneous A^mputations—Structure of a Stump—Artiflcial Limbs—Morbid Condition of Stumps—A\neurismal Enlargement of Arteries —Painful and Spasmodic Stumps—Strumous, Malignant, and Fatty Degene¬ ration of Stumps.—M orTaALITT aAFTER aImputation—A\. ge—General Health —Hygienic Conditions—Seat of A\mputation—Part of Bone—Injur}' or Dis¬ ease—Nature of Disease—Time of Performance—Primary and Secondary Amputations—Statistics.. 40-o9 Ch.APTER III.—SpECIaAL AmPUTaATIONS. Upper Limb—F ingers—Metacarpo-Phalangeal Joints—Thumb^Metacarpal Bones—AVrist—Forearm—A\rm—Shoulder-Joint—General Results of A\mpu- tations of the Upper Limb.—L ower Limb—T oes—Metatarsal Bones— Chopart’s Operation—Syme's Disarticulation of the Ankle-Joint—PirogofTs Operation—Subastragaloid Almputation—Results of Almputations of Foot— Amputations of the Leg—Flap A^mputation—Results—Almputation through the Knee-Joint—Yermale’s Operation—Amputation of Upper and Middle Thirds of the Thigh—Through the Trochanters—Results of A\mputation of Thigh—A^mputation at Hip-Joint—Results.59-92 X CONTEXTS. Chapter IY_Inflammation. PAGE Congestion —Symptoms—Effects—Causes—Treatment.— Determination — Symptoms—Effects—Causes—Treatment.— Acute Inflammation — Phe¬ nomena—Condition of Vessels—State of Blood—Symptoms—Local Signs— Constitutional Symptoms—Inflammatory Fever—Sthenic, Asthenic, and Irritative—Terminations, Extension, and Effects of Acute Inflammation— Varieties—Causes—Treatment.— Chronic Inflammation — Pathology— Phenomena—Constitutional Symptoms—Causes—Treatment . . 92-122 Chapter Y.—Suppuration and Abscess. Suppuration —Characters of Pus—Diagnosis—Pyogenesis—Relation of Supy puration to other Changes in the Tissues—Circumstances influencing the Tendency to Suppuration—Duration—Symptoms—Forms in which Suppu¬ ration occurs.— Abscess —Definition—Varieties—Acute or Phlegmonous— Chronic—Cold, Lymphatic or Congestive—Diffuse—Puerperal—Metastatic —Tympanitic or Emphysematous—Situation and Size—Effects—Diagnosis —Prognosis—Treatment—Of Acute Abscess—Of Chronic Abscess—Tumors —Tapping — Potassa Fusa — Drainage-Tubes — Antiseptic Treatment— Hemorrhage into Cavity of Abscess.— Sinus and Fistula —Causes and Structure—Treatment.123-141 Chapter YI.—Ulceration. Ulceration defined—Causes—Situation—Stages—Repair of Ulcers—Granu¬ lation—Cicatrization—Treatment—Transplantation of Cuticle.— Forms of U LCER —Healthy or Purulent—Weak—Indolent — Irritable — Ipflamed— Sloughing—Varicose—Hemorrhagic—On Mucous Membranes . 141-152 Chapter YII. —The Process of Repair. 3Iodes of Union of Wounds —First Intention—Scabbing or Incrustation— Adhesive Inflammation — Vascularization of Lymph — Degeneration of Lymph—Granulation—Union of Granulating Surfaces — Circumstances aflecting the Healing Process.152-158 DIYISIO^T SURGICAL INJURIES. Chapter YIII. —Effects of Injury. Shock —Symptoms—Causes—Pathology—Treatment.— Traumatic Fever.— Traumatic Delirium.—Remote Effects of Injury —Constitutional— Local .159-104 COXTEXTS. XI Chapter IX.—Injuries of Soft Parts. PAGE CoNTUsiONS—Causes — Degrees — Diagnosis — Treatment — Strangulation of Parts.—WOUNDS—How classified.—I ncised Wounds—S ymptoms—Man¬ agement—Local Treatment—Antiseptic Treatment of Wounds—Inflamma¬ tion of Incised Wounds.—C ontused and Lacerated Wounds—S lousrh- o ing—Traumatic Gangrene — Treatment — Indications for Amputation.— Brushburn—T reatment.—P unctured Wounds—T reatment . 164-187 Chapter X.—Gunshot Wounds. Gunshot Wounds in General—C ircumstances affecting Character—Xature and Force of Projectile—Direction—Apertures of Entry and Exit—Symp¬ toms—Treatment—Hemorrhage—Extraction of Foreign Bodies—Treatment of Wound—Cases requiring Amputation.—G unshot Wounds of Special Bones and Joints. 187-205 Chapter XI.—Poisoned Wounds. Stings.—Snake-Bites — Effects of Snake-Poison—Treatment.—B ites of Rabid Animals — Hydrophobia — Symptoms — Prognosis — Pathology — Treatment.—W ounds with Inoculation of Decomposing Animal Mat¬ ter—C auses—Symptoms—Treatment. 206-215 Chapter XII.—Effects of Heat and Cold. Burns and Scalds—L ocal Effects—Degrees—Constitutional Effects—Progno¬ sis—Mode of Death from Burns—Treatment—Prevention and Removal of Contraction—Warty Cicatrices—Amputation.—F rost-Bite—L ocal Influ¬ ence of Cold—Constitutional Effects—Treatment .... 216-227 Chapter XIII.—Injuries of Bloodvessels. Injuries of Veins—V enous Hemorrhage—Diffuse Phlebitis.—I njuries of Arteries—C ontusion—Rupture and Laceration—Wounds, Xon-Penetra- ting and Penetrating.—H emorrhage from Wounded Vessels—L ocal Sis:ns—Distinctive Characters of Arterial and Venous—Extravasation— Constitutional Effects—General Treatment—Transfusion of Blood . 227-232 Chapter XIV.—Arrest of Arterial Hemorrhage. Natural Arrest of Hemorrhage—H istory of Investigations—Temporary Means—Changes in the Blood and in the Heart’s Action—Retraction and Contraction of the Artery—Formation of Coagulum—Permanent Closure— Adhesion—Contraction—Arrest of Hemorrhage from Punctured Arteries.— Surgical Treatment—T emporary Means—Compression of Artery—Tour¬ niquet— Permanent Means—Cold—Styptics—Cauterization—Direct Pres¬ sure — Forcible Flexion—Torsion — Ligature—History—Principles—Appli¬ cation — Modifications — Effects — Acupressure — Collateral Circulation.— Accidents after Arterial Occlusion by Surgical Means—S econdary Hemorrhage—Gangrene .. 232-269 XU CONTENTS. Chapter XT.— Traumatic Aneurism and Arterio-Tenous Wounds. PAGE Traumatic Aneurism — Diffused — Circumscribed. — Arterio-Venous Wounds —Aneurismal Tarix—Varicose Aneurism .... 270-27G Chapter XVI.— AVounds of Special Bloodvessels. Vessels of Head and Xeck— Carotid Artery — Aneurismal A^arix of Inter¬ nal Jugular A^ein—Traumatic Aneurism of Temporal Artery—Deep Arte¬ ries of Face.— Vessels of Upper Limb —Subclavian Artery—AYound— Aneurismal A'arix — Axillary — Open AA'ounds — Traumatic Aneurism— Bracliial Artery—AA'ounds—Traumatic Aneurism—A^aricose Aneurism— Aneurismal A^arix—Arteries of the Forearm and Palm—Traumatic Aneurism of Kadial and Ulnar Arteries—AYounds of Palmar Arteries—Circumscribed Traumatic Aneurism in the Palm.— Vessels of Lower Limb— Femoral Artery and its Branches—Diffused Traumatic Aneurism—Arteries of the Leg and Foot—AYounds and Traumatic Aneurisms—Traumatic Aneurism of Gluteal Artery. 276-285 Chapter XA^II.—Entrance of Air into A^eins. Air in Veins— Results of Experiments on Animals—Spontaneous Entry in Alan—Local Phenomena—Constitutional Effects—Cause—Preventive Treat¬ ment—Curative Treatment—Indications to be followed . . . 286-292 Chapter XA'III.—Injuries of Xerves, AIuscles, and Tendons. Injuries of Nerves—C ontusion—Puncture—Division—Repair.—I njuries OF AIuscles and Tendons—S prains or Strains—Rupture and Division— Union—Treatment. 292-295 Chapter XIX. —Injuries of Bones and Joints. Injuries of Bones—B ruising—Bending.—I njuries of Joints—C ontu¬ sions—Sprains—Treatment—AA’^ounds of Joints—Symptoms and Effects— Traumatic Arthritis—Treatment.—AA ^ounds of Individual Joints—H ip and Shoulder—Knee—Ankle—Elbow—AYrist ..... 296-301 Chapter XX. —Fractures. Fracture —Causes—Y"arieties—Nature—Direction—Signs—Union—In Sim¬ ple Fracture—In' Compound Fracture.— Treatment of Simple Frac¬ ture —Reduction—Prevention of Return of Displacement—Bandages— Splints—Starched Bandage—Plaster of Paris Bandage.— Accidents during Treatment —Spasm—Extravasation of Blood—(Edema and Gangrene— Pulmonary and Cerebral Congestion.— Complicated Fractures —Treat¬ ment.— Compound Fracture —Removal of the Limb—Treatment of Com¬ pound Fracture—Bending, Rebreaking, and Resetting Bones—Delayed Union—Ununited Fracture and False Joint. 301-339 CONTENTS. Xlll Chapter XXI. —Special Fractures. PAGE Bones op the Face —Nasal Bones—Ma^ar and Upper Jaw Bones—Lower Jaw—Hyoid Bone.— Bones of the Chest —Ribs and Costal Cartilages— Sternum.— Upper Extremity —Clavicle—Scapula—Humerns—Forearm— Metacarpus and Fingers.— Lower Extremity —Pelvis—Sacrum—Coccyx —Femur—Patella—Tibia and Fibula—Foot. 340-390 Chapter XXII. —Dislocations. Dislocation defined—Causes—Signs—Effects—Treatment—Mechanical Con¬ trivances—Extension—Dislocation of old Standing—Treatment—Dangers of Attempts at Reduction—Compound Dislocation—Treatment—Complica¬ tions—Spontaneous Dislocation—Congenital Dislocation . . . 390-401 Chapter XXIII. —Special Dislocations. Lower Jaw —Causes—Bilateral—Unilateral—Reduction—Congenital Dislo¬ cation.— Clavicle —Sternal End—Acromial End—Simultaneous of both Ends.— Scapula. — Humerus —Varieties — Subcoracoid — Subclavicular— Subspinous — Subglenoid—Partial—Causes — Relative Frequency—Diagno¬ sis—Treatment—Compound — Congenital — Unreduced—Accidents in At¬ tempted Reduction. —Elbow Joint— Both Bones—Ulna—Radius—Com¬ plications—Treatment—Compound—Old Unreduced Dislocations.— Wrist — Backwards — Forwards — Diagnosis — Compound — Congenital.— Single Carpal Bones — Os Magnum — Pisiform — Semilunar. — Metacarpal Bones. — Metacarpo-Phalangeal Joints — Thumb.— Phalanges op Fingers. — Pelvis —Pubic Symphysis—Sacro-Iliac Articulation—Coccyx. — Hip —Cooper’s Classification—Importance of Ilio-Femoral Ligament— Bigelow’s Classification—Varieties—Modes of Reduction—Ilio-Sciatic—On Thyroid Foramen—On Pubic Bone—Other Forms—Reduction of Old Dis¬ locations—Complication with Fracture—Simultaneous.— Patella. — Knee —Varieties—Subluxation — Complications — Compound Dislocation—Head of Fibula.— Ankle —Varieties' — Compound.— Astragalus — Varieties — Treatment—Compound.— Tarsal Bones —Calcaneum and Scaphoid—Cal- caneum—Scaphoid and Cuboid —Great Cuneiform.— Metatarsal Bones 402-445 Chapter XXIV. —Injuries of the Head. Cerebral Complications of Injuries op the Head —Concussion—Com¬ pression—Cerebral Irritation—Contusion of the Brain—Effects of Cerebral Injury on Mental Powers—Traumatic Encephalitis—Intracranial Suppura¬ tion—Treatment of Cerebral Injuries and their Effects.— Injuries of the Scalp — Contusions— Cephalhaematoma—Wounds.— Fractures of the Skull —Contusion of Cranial Bones—Causes and Varieties of Fracture— Contre-coup—Simple Fracture—Fracture of the Base of the Skull—Signs —Hemorrhage—Discharge of Watery Fluid—Depressed Fracture—Varieties —Symptoms—Wounds of the Dura Mater—Treatment of Depressed Frac¬ ture— Injuries op the Contents of the Cranium —Wounds of the Brain and its Membranes—Causes—S3unptoms and Effects—Diabetes—Injuries of Cranial Nerves—Fungus or Hernia Cerebri—Extravasation of Blood within the Skull—Symptoms—Diagnosis—Operation of Trephining. . . 446-484 XIV CONTEXTS. Chapter XXY.—Injuries of the Spine. PAGE Concussion of the Spinal Cord —Definition.— Concussion fron Direct Violence— Primary Symptoms — Secondary Symptoms — Causes of Death — Injuries of Vertebral Column—Effects of Slight Blows.— Concussion from Indirect Violence —Secondary Effects—Pathological Conditions—Diag¬ nosis — Prognosis of Spinal Concussion — Treatment. —Wounds of the Spinal Cord— Symptoms — In Lumbar and Lower Dorsal Region — In Middle Dorsal Region—In Lower Cervical Region—Above Phrenic Nerve. — Mechanical Injuries of the Vertebral Column.—Sprains —Symp¬ toms — Prognosis. —Fracture— Signs and Symptom.s — Treatment. —Dis¬ locations —Of Atlas from Occipital Bone—Of Axis from Atlas—Of Lower Cervical Vertebrse—Of Transverse Processes of Cervical Vertebrae—Of Dor¬ sal Vertebrae. 484-508 Chapter XXVI.—Injuries of the Face and Adjacent Parts. Face —Cuts of Cheeks and Forehead—Lips—Parotid Duct—Salivary Fistula —Foreign Bodies in Nose.—EARS--Wounds—Foreign Bodies.— Orbit — Danger of Injuries of.— Eye— Contusion—Contusion with Rupture— Wounds, Penetrating and Non-Penetrating—Indirect Injury of the Eye.— Mouth.—Tongue.—Palate and Pharynx. 508-517 Chapter XXVII.—Injuries of the Throat: and Asphyxia. Injuries of the Larynx and Trachea—D islocation and Fracture of Larynx [ —Wounds of Throat—Not extending into Air-passage—Implicating Air- passage—Treatment—Aerial Fistula—Foreign Bodies in Air-passage—Symp¬ toms—Prognosis—Treatment—Scald of Mouth, Pharynx, and Glottis— Treatment.—A sphyxia or Apncea—C auses—From Drowning—Artificial Respiration—Inflation with Oxygen Gas—Secondary Asphyxia-^From Nox¬ ious Gases—From Hanging.—P harynx and (Esophagus—W ounds— Foreign Bodies—Pharyngotomy and (Esophagotomy . . . 517-534 Chapter XXVIII.—Injuries of the Chest. Wounds of the Chest. — Injuries of the Luno-^ Contusion—Rupture— W ound — Symptoms — Complications — Hemorrhage — Hsemothorax—Em¬ physema and Pneumothorax—Pneumonia—Pleurisy and Empyema—Col¬ lapse of Lung—Prognosis—Treatment—Hernia of Lung, or Pneumocele.-r Wounds OF the Heart and Large Vessels —Wounds of the Pericardium —Wounds of the Heart—Rupture of the Heart from External Violence— Wounds of the Aorta and Vena Cava. 534-546 Chapter XXIX.—Injuries of the Abdomen and Pelvis. Injuries of the Abdomen and Abdominal Viscera —Contusion of the Abdominal Walls—Buffer-Accidents—Rupture of Abdominal Viscera—Em¬ physema of Abdominal Wall—Wounds of Diaphragm—Wounds of Ab¬ dominal Wall—Non-penetrating—Penetrating—Without Wound or Protru¬ sion of Viscera—With Wound or Protrusion—Wounds of Intestine— CONTEXTS. XV PAGE Treatment—Traumatic Peritonitis—Treatment.— Injuries of the Pelvic Viscera- Rupture of Bladder—Foreign Bodies in Bladder—Rupture of Ureter—Wounds of Organs of Generation—Wound of Urethra—Laceration of L^retlira—Foreign Bodies in Vagina or Rectum—Laceration of the Peri- ncTum.. 547-564 DIVISIOX THIRD. SURGICAL DISEASES. Chapter XXX. —Mortification, or Gangrene. Gangrene Defined —Local Signs—Constitutional Symptoms—Causes—Gan¬ grene from Arrest of Supply of Arterial Blood—Ligature or Wound of Artery—Thrombosis—Embolon—Senile Gangrene—Gangrene from Obstruc¬ tion of Circulation through a Part—Venous Obstruction—Strangulation— Inflammation—Arrest of Gangrene—Lines of Demarcation and Separation —Diagnosis —Prognosis — Treatment — Constitutional — Local — of Senile Gangrene—Amputation. 565-570 Chapter XXXI. —Gangrenous Diseases. Bed-Sores —Treatment. —Sloughing Phagedena —Local Signs—Constitu¬ tional Symptoms—Causes—Treatment.— Gangrenous Stomatitis or Can- crumOris —Signs—Treatment. —Boils— Causes—Treatment. —Carbuncle —Signs—Diagnosis—Prognosis—Treatment. 579-588 Chapter XXXII. —Erysipelas. Erysipelas— Characters—Erysipelatous Fever—Causes—Intrinsic—Hygienic Influences—States of Blood — Extrinsic — Season—Contagion. —External Erysipelas —Cutaneous—Cellulo-Cutaneous— Cellular — Diagnosis—Prog¬ nosis—Treatment—Of Cutaneous Erysipelas—Of Cellulo-Cutaneous Ery¬ sipelas—Of Cellular Erysipelas—Special Forms—In Xewly born Infants— Orbit — Head — Scrotum — Pudenda — Whitlow. —Internal Erysipelas— Erysipelas of Mucous Membranes—Fauces—Larynx—Of Serous Membranes —Arachnoid—Peritoneum . . . •. 588-606 Chapter XXXIII. —Py^^mia. Pyemia Defined—C auses—Phenomena—Formation of Purulent Deposits— Diagnosis—From Inflammatory and Typhoid Fevers—From Ague—From Rheumatism—Prognosis—Pathology—Leucocytosis—Trombosis and Em¬ bolism—Formation and Changes of a Thrombus—Embolon—Ichorrhsemia or Septicgemia—Post-mortem Appearances—Blood—Heart—Lungs—Liver —Spleen—Kidneys—Intestines—Joints—General Character of Anatomical Lesions—Treatment. 606-621 XVI CONTENTS. Chapter XXXIY.—Tumors. PAGE Deposition. — Classification— Non-malignant, Benign, or Innocent Tu¬ mors—Malignant Tumors—Signs of Malignancy—Semi-malignant Tumors — Clinical Classification — Anatomical Classification,—I. Cystic Tumors — Classification according to Contents—Dermoid Cysts—Serous Cysts—Colloid Cysts—Classification according to Development—Encysted Tumors from Simple Distension of Walls of Duct or Cyst—Of Sebaceous Glands—Pro¬ gress—Diagnosis—Treatment—Of other Excretory Organs—Distension of Cavities without Excretory Ducts—Bursae—Cystic Tumors of Ovary— Cysts as New Formations—Simple or Serous Cysts—Compound, Prolifer¬ ous, or Multilocular Cysts—Sanguineous Cyst or Haematoma—Pilo-C 5 ^stic Tumors or Dermoid Cysts — Cholesteatoma.—II. Tumors Produced ry Local Hyperplasia of Complex Structures —Tumors connected with Integumental Structures—Corns—Warts—Condylomata and Mucous Tu¬ bercles—Cheloid—Treatment—Polypi—Hypertrophy of Glandular Struc¬ tures.—III. Tumors of the Connective Tissue Type— Classification —Derived directly from Connective Tissue—Fatty and Adipose Tumors— Lipoma—Fibroid Tumors—Malignant—Fibroid—Sarcomata—Areolar Tu¬ mors—Fibro-cellular Tumors—Glioma and Myxoma—Recurring Fibroid Tumors—Fibro-Plastic and Myeloid Tumors—Granulation Tumors—Tu¬ mors formed on the Type of Cartilage—Enchondroma—Microscopical Characters—Locality—Treatment—Tumors formed on the Type of Bone.— IV. Tumors of the Epithelial Type— Cancer—Scirrhus and Encepha- loid—Microscopic Structure—Progress—Scirrhus—Structure—Encephaloid —Structure—Other Varieties of Cancer—Colloid, Gelatinous, or Alveolar— Melanosis or Black—Causes—Diagnosis of Forms of Cancer—Causes— Mental Emotions—Constitutional or Local Origin—Secondary Deposits— Treatment—Constitutional Means Useless—Local Means—Palliative—Cura¬ tive—Caustics—Acids—Alkalies—Chlorides—Arsenic—Sulphate of Zinc— Compression—Excision—Question of Operating—Cases not Admitting Operation—Doubtful Cases—Cases Proper for Operation.— EpiIthelioma — Situation and Progress —Structure—Diagnosis—Prognosis—Treatment— Excision—Ligature—Ecraseur—Caustics.— Excision of Tumors . 621-674 Chapter XXXV _Scrofula and Tubercle. Scrofula —Definition—Scrofulous Diathesis—Scrofulous Temperament—Stru¬ mous Inflammation—Of Skin—Mucous Membranes—Bones and Joints— Glandular Organs.— Tubercle —Structure—Progress.— Causes of Scro¬ fula AND Tubercle— Hereditary Nature — Malnutrition — Debility from Disease. —Treatment —Preventive—Curative—Local Treatment.— Opera¬ tions IN Scrofulous and Tuberculous Cases .... 674-683 Chapter XXXVI. —Venereal Disease. Definition and Classification.—I. Local Contagious Ulcer or Chan¬ cre —Characters—Specific Nature—Origin and Progress—Varieties—Simple or Soft—PhagedfBiiic—Sloughing Chancre, or Gangrenous Phagedaena— Situation of Chancre—Diagnosis—Local Treatment of Chancre—Of Phage- daenic Chancre—Of Sloughing Chancre—Constitutional Treatment.— Con¬ secutive Symptoms of the Local Contagious Ulcer —Contracted CONTENTS. XVll PAGE Cicatrices—Bubo—Primary Bubo—Creeping Bubo—Treatment—Venereal "Warts.—II. Syphilis, or Constitutional Venereal Disease —Cha¬ racters—Origin—Transmisibility—Progress—Indurated or Hunterian Chan¬ cre—Seat and Number—Induration—Indolent Enlargement of Lymphatic Glands—Treatment—Use of Mercury.— Secondary or Constitutional Manifestations of Syphilis —Phenomena—Circumstances Influencing Progress—Treatment—Mercury,— Local Secondary Affections— Syphi¬ litic Skin Diseases—Warts, Excrescences, and Vegetations—Syphilis of Mucous Membranes—Syphilitic Iritis—Periosteum and Bones—Nodes— S 3 ’'philitic Necrosis and Caries—Sj-philitic Disease of Testicle—S 3 'philitic Ovaritis—S 3 ^philis of Muscles and Tendons.— Infantile Syphilis— Nature—Mode of Communication—S 3 unptoms — Influence on Teeth — Treatment ............ C83-725 Chapter XXXVII _Surgical Diseases of the Skin and its Appendages. Diseases of the Appendages of the Skin —Warts—Corns—Diseases of the Nails-Onychia—Ingrowing of the Nails—Hypertropln^ of Toe-Nail.— Malignant Tumors and Ulcers of the Skin —Cheloid and Fibro- Vascular Tumors—Lupus—Varieties—Lupus Mon exedens—Lupus Exedens —Microscopic Structure—Diagnosis—Treatment—Lupoid or Eodent Ulcer —Symptoms—Patholog 3 "—Treatment—Cancer of the Skin—Scirrhous Wart —Infiltrated Cancer—Cancerous Ulcer—Treatment .... 725-737 Chapter XXXVIII. —Diseases of the Nervous System. Neuritis — Symptoms —Treatment.— Neuralgia — S 3 miptoms — Causes— Diagnosis — Treatment. — Neuroma — Structure — Traumatic Neuroma — Treatment.— Traumatic Paralysis —From Injuiy of Brain—From Injuiy of Spinal Cord—From Pressure on Nerves—Diagnosis.— Tetanus —Causes —Period of Occurrence—Forms—Symptoms—State of Nerves at Seat of Injury—Pathology—Treatment. 737-754 Chapter XXXIX. —Diseases of the Lymphatics and tiieip*. Glands. Inflammation of the Lymphatics, Lymphatitis, or Angeioleucitis— Symptoms—Kesults—Diagnosis—Causes—Treatment.— Inflammation of Lymphatic Glands, or Adenitis— Varieties—Strumous Enlargement of Glands—Treatment.— Other Diseases of Lymphatics and their Glands —L 3 unphadenoma—Elephantiasis of the Legs and Scrotum—Varix of the Lymphatics. 754-7G1 I Chapter XL. —Diseases of Veins. Phlebitis —Idiopathic and Traumatic—Pathology—Embolic—Symptoms— Treatment — Diffuse Phlebitis—S 3 miptonis —Treatment.— Varix — Defini¬ tion—Appearance—Locality—Causes—Structure—Treatment—Obliteration of Varicose Veins. 761-768 VOL. 1.—B XVlll CONTEXTS. PAGE Chapter XLI. —Aneurism by Anastomosis; and X^vus. Aneurism by Anastomosis— Xature—Diagnosis—Treatment.— Xa^vus — Capillary—Venous Structure—Treatment—Operations on—Ligature of.— Xacvi in Special Situations —Scalp—Fontanelle—Face—Eyelids—Xose —Cheeks—Lips—Tongue—Penis—Vulva and Pudendum—Extremities, Neck, and Trunk—Xaevoid Lipoma.— Hemorrhagic Diathesis— Causes —Treatment. 708-781 \ LIST OF ILLUSTRATIONS TO YOL I. FIG. 1. Clover’s chloroform apparatus ...... 2. AcVBinistration of chloroform by Clover’s apparatus 3. Lines of incision in Teale’s amputation ..... 4. Teale’s amputation : stump ...... 5. Artery of thigh-stump laid o^Den ...... G. Nerve in a stump of forearm ...... 7. Necrosed end of femur from stump ..... 8. Aneurismal varix in a stump ...... 9. Amputation of part of a finger by cutting from above 10. Amputation of a linger. Cutting the flap by transfixion •11. Amputation of a finger. Removing the head of the metacarpal bone . 12. Amputation of index finger. Removing the head of the metacarpal bone ......... 13, 14, 15. Results of amputation above metacarpo-phalangeal articulation in middle, index, and ring fingers . . . . . 16. Amputation of the left thumb and metacarpal bone 17. Amputation of right thumb by transfixion. Cutting the anterior flap . 18. Result of amputation of the thumb. . . . . . 19. Hand after amputation of metacarpal bones and first two fingers 20. Hand after removal of metacarpal bones and three fingers, leaving thumb and little finger ........ 21. Amputation at the wrist ....... 22. Amputation of the forearm. Transfixion of the anterior flap 23. Amputation of the arm. Clearing the bone .... 24. Amputation at the’shoulder-joint b}’ transfixion .... 25. Amputation at the shoulder-joint. Opening the capsule, and making inner flap ......... 2G. Amputation at the shoulder-joint. Holding vessels in the inner flap 27. Stump after amputation at the shoulder-joint .... 28. Amputation at shoulder by Spence’s method .... 29. Incision in amputation of a toe ...... 30. Removal of metatarsal bone of great toe; flap formed; joint being opened ......... 31. Amputation of the great toe by oval method . . . . 32. Removal of metatarsal bone of little toe : flap formed : bone being cleared ......... 33. Line of Hey’s operation ....... 34. Line of Chopart’s operation ...... 35. Chopart’s operation : flap formed before disarticulation . 36. Chopart’s operation : flap formed after disarticulation 37. Line of amputation of great toe ...... 38. Syme’s amputation of the foot. Clearing the os calcis . 39. Syme’s amputation of the foot. Anterior incision and disarticulation . 40. Syme’s disarticulation at ankle-joint • . . . . 41. Syme’s amputation of the foot. Sawing off the malleoli. 42. Pirogoff’s amputation : application of saw to os calcis 43. PirogoflTs amputation : appearance of parts after removal of malleoli . 44. Stump after Pirogoff's amputation ...... 45. Amputation of the right leg. Transfixion of the posterior flap . PAGE 30 30 44 44 49 49 50 51 59 GO 61 62 62 63 64 64 64 64 65 65 66 67 68 69 69 70 71 71 < o 73 74 74 74 75 75 76 76 78 78 78 80 XX LIST OF ILLUSTRATIONS TO VOL. I. FIG. PAGE 4G. Amputation of the leg. Sawing the hones . . . .81 47. Amputation through the knee by long anterior flap . . .82 48. Amputation through the condyles by long posterior flap . . 83 49. Amputation at knee by lateral flaps . . . . .84 50. Amputation of the lower third of the thigh by lateral flaps . . 85 51. Amputation of the thigh : entero-posterior flap operation . . 86 52. Amputation of thigh : formation of posterior flap by transflxion : of anterior, by cutting from without inwards . . . .86 53. Lister’s aorta-compressor applied .... . . 88 54. Amputation at the hip-joint: formation of anterior flap in left limb . 88 55. Amputation at the hip-joint: formation of anterior flap in right limb . 89 56. Amputation at hip-joint; compression of femoral artery in anterior flap ......... 91 57. Irrigating apparatus ....... 109 58. Introduction of a seton ....... 122 59. Healthy pus-cells ........ 123 60. Pus-ceils from pj-^emic abscess ...... 124 61. Pus-cells from scrofulous abscess . . . . . .124 62. Large lumbar abscess extending down the thigh and leg . .130 63. Suction-trocar ........ 132 64. Abscess bistoury . . . . . . . .133 65. Introduction of seton through canula ..... 135 66. Forked probe for introducing drainage-tube . . . .136 67. Drainage-tube and forked probe ...... 136 68. The serreflne ........ 171 69. Forceps for removing small pointed bodies ... . . 187 70. Perforation of right femur by bullet. Longitudinal splitting of bone (United States Army Museum.) ..... 189 71. Gunshot wound. Aperture of entry . . . . .190 72. Gunshot wound. Aperture of exit ..... 190 73. Gunshot wound of thigh ; mode of compressing artery temporarily . 195 74. Xelaton’s probe ........ 196 75. 76, 77. Bullet-screw, forceps, and extractor .... 196 78. Bullet-forceps . . . . . . . . 196 79. Hook splinter forceps . . . . . . .196 80. Bullet in head of humerus . . ... . . 203 81. Contraction of elbow from cicatrix of burn of fourth degree . . 221 82. Contraction of thumb from burn of fourth degree . . . 221 83. Dislocation backwards of little Anger from contraction of the cicatrix of a burn of the fourth degree ...... 222 84. Deformity of right hand from burn of the fourth or flfth degree . 222 85. Deformity of left hand from burn of the Arth degree . . . 222 86. Deformed foot from burn of the fourth and flfth degrees . . 223 87. Cicatrix of lip and neck before operation .... 224 88. The same patient after operation ...... 224 89. Incisions in Teale’s operation for cicatricial deformit}^ of the lower lip. 224 90. Teale’s operation : the flaps in place ..... 224 91. Pressure with thumbs. Application of tourniquet to femoral artery . 238 92. Torsion of brachial artery . ...... 241 93. End of artery drawn forwards. Application of ligature . . 247 94. Liston’s “ bull-dog” forceps modiflecl ..... 247 95. A reef-knot ......... 248 96. Exposure and opening of the sheath ..... 249 97. Opening in the sheath : vessels exposed ..... 249 98. Passage of the needle and ligature ..... 250 99. Femoral artery, fifty-six hours after amputation . . . . 253 100. Brachial artery, ten days after amputation .... 253 101. Femoral arteiy, six weeks after amputation .... 253 102. Partial absorption of coagulum in femoral, fourteen days after amputa¬ tion ......... 254 103. Femoral arteries, teu days after amputation of thigh. Death from pyaemia ......... 254 104. Acupressure. First method. Raw surface .... 256 105. Acupressure. First method. Cutaneous surface . . . 256 106. xVcupressure. Second method ...... 256 LIST OF ILLUSTRATIONS TO VOL. I. XXI FIG. PAGE 107. Acupressure. Third method ...... 257 108. Acupressure. Fourth method ...... 257 109. Anastomosing circulation in sartorius and pectineus of dog, three months after ligature of femoral. (After Porta.) . . . 201 110. Direct anastomosing A'essels of right carotid of goat, five months after ligature. (After Porta.) . . .... 261 111. Change in the trunk after ligature, "svith anastomosing vessel . . 261 112. Circumscribed traumatic aneurism in ball of thumb after a powder- flask explosion ........ 272 113. A varicose aneurism at the bend of the arm unopened . . . 274 114. The same varicose aneurism removed from its connections . . 275 115. The same tumor laid open, showing the circumscribed false aneurism between the two vessels ....... 275 116. The opened tumor removed from its connections. Application of liga¬ tures ......... 276 117. Oblique and longitudinal fractures ..... 304 118. Comminuted fracture of the humerus without displacement . . 308 119. Section of fractured tibia, four weeks after accident . . . 310 120. Starched bandage applied to fractured thigh .... 316 121. Seutin’s pliers ........ 316 122. Application of Seutin’s pliers to starched bandage . . . 317 123. Starched bandage : trap left for dressing wound . . .317 124. Bavarian plaster splint: adjustment of the flannel layers . . 319 125. Gangrene of forearm and hand from tight bandaging . . . 321 126. Apparatus for ununited fracture of femur .... 337 127. Archimedean drill for perforating bone ..... 338 128. Gutta percha splint: original shape ..... 342 129. Gutta percha splint moulded to shape of jaw .... 342 130. Apparatus applied to fracture of lower jaw .... 343 131. Healthy clavicle ........ 347 132. Fracture of clavicle, outside of trapezoid ligament . . . 347 133. Apparatus for fractured clavicle ...... 349 134. Apparatus for fracture of the neck of the humerus . . . 353 135. Transverse fracture of humerus. Separation of condj'les . . 355 136. Paralysis of hand (wrist-drop) after fracture of humerus . . 356 137. Permanent flexure from paral 3 "sis after fracture of humerus . . 356 138. Apparatus for wrist-drop after fracture of the humerus . . 357 139. Fracture of lower end of radius: side view . . . . 359 140. Fracture of lower end of radius: hack view . . . . 359 141. Fracture of lower end of radius : displacement of articular surface . 360 142. Fracture of lower end of radius : displacement of lower fragment . 360 143. Nelaton's apparatus for treatment of fracture of the lower end of the radius ......... 362 144. Attitude of limb in intracapsular fracture of the neck of the thigh¬ bone ......... 367 145. Simple extracapsular fracture of the neck of the thigh-bone : detach¬ ment of the trochanter ....... 370 146. 147. Section of impacted extracapsular fractures of neck of femur: showing the degree of impaction and of splintering in different cases 371 148. Union in impacted extracapsular fracture of neck of femur . . 371 149. Impacted extracapsular fracture of neck of femur ; abundant forma¬ tion of callus ........ 371 150. Liston’s long splint ....... 375 151. Compound fracture of shaft of thigh-bone : treatment b}" bracketed long splint ......... 375 152. Fracture of shaft of thigh-bone : treatment by weights and short splints 376 153. Limb suspended from splint by slings, preparatory to application of roller ......... 376 154. Impacted fracture of lower end of thigh-bone .... 378 155. 156. Fracture of condjTes from fall on the bent knees . . . 378 157. Fractured patella : side view of limb, straight .... 379 158. Fracture of patella : separation between fragments increased by bend¬ ing the knee ........ 379 159. M’Intyre’s splint, modified by Liston ..... 382 160. Salter’s swing-box for fractured leg ..... 383 XXll LIST OF ILLUSTRATIONS TO YOL, I. FIG. PAGE 161. Fractures of tibia and fibula above ankle .... 885 162. Pott’s fracture: application of Dupin^tren’s splint . . . 387 163. Comminuted fracture of astragalus; displacement backwards . . 389 164. Bandage applied for extension : clove-hitch knot . . . 394 165. Dislocation of the clavicle on the acromion .... 405 166. Subglenoid dislocation of the head of the humerus . . . 407 167. Subclavicular dislocation of the head of the humerus . . . 407 168. Subcoracoid dislocation of the bead of tl>e humerus . . . 407 169. Subspinous dislocation of the head of the humerus . . . 407 170. Subcoracoid dislocation of humerus ..... 408 171. Subglenoid dislocation ....... 409 172. Reduction of dislocated shoulder-joint by the heel in the axilla . 411 173. Dislocation of the radius forwards : limit of power of bending the arm 417 174. Dislocation of the radius forwards : deformity of outer side of the arm when extended . . . . . . '.417 175. Position of the bones in an old unreduced dislocation of the radius for¬ wards . . . . . . . . .417 176. Dislocation of the ulna: reduction . . . . .419 177. Dislocation of the hand and carpus forwards .... 420 178. Dislocation of the nvtacarpus ; forwards, from the carpus . . 422 179. Dislocation backwards of the proximal phalanx of the thumb . 423 180. Partial dislocation of the middle phalanx of the iniddR finger . 424 181. Dislocation of the head of the thigh-bone, according to Astley Cooper’s classification. Upwards, and somewhat backwards, on dorsum ilii 426 182. -Backwards into sciatic notch . ..... 426 183. -Downwards into foramen ovale ..... 426 184. -Forwards and upwards on the pubic bone .... 426 185. Dislocation below the tendon. Much inversion. (Bigelow.) . . 429 186. Dorsal dislocation. Reduction by rotation. Tlie limb has been flexed and abducted, and it remains only to evert it and render the outer branch of the Y-ligament tense by rotation. (Bigelow.) . . 430 187. Reduction of ilio-sciatic dislocation b}" extension . . . 431 188. Dislocation downwards and outwards towards the tuberosity below tendon. (Bigelow.) . . ... . . . 431 189. Thyroid dislocation. (Bigelow.) ..... 432 190. Reduction by manipulation in thyroid dislocation. Rotation and cir¬ cumduction inwards of head of femur. (Bigelow.) . . . 432 191. Reduction of dislocation into obtura or foramen by extension . . 433 192. Dislocation directly downwards. (Bigelow.) .... 433 193. Dislocation downwards and inwards towards perinaeum. (Bigelow.) 433 194. Pubic dislocation. (Bigelow.) ...... 434 195. Pubic dislocation. Head of bone in groin suspended by Y-ligament. (Bigelow.) ........ 434 ^ 196. Reduction of pubic dislocation by extension .... 435 197. Subspinous dislocation. The Y-ligament is stretched across the neck of the bone, which lies beneath it. (Bigelow.) . . . 435 198. Dissection of foot in compound dislocation of astragalus outwards . 444 199. Fracture of the skull from gunshot injuiy from within : splintering of outer table . . . . . . . . 469 200. The same—natural size ....... 469 201. Apparatus for fracture of spine ...... 505 202. Ear-scoop ......... 509 203. Split sheet applied : ends knotted ...... 530 204. Application of suture to wounded bowel .... 555 205. Operation for lacerated perinaeum ..... 563 206. Obstruction of femoral artery at its bifurcation by an embolon . . 568 207. Femoral and tibial arteries obstructed in senile gangrene . . 569 208. Senile gangrene : exposure of bones of foot .... 569 209. Senile gangrene of foot: line of separation .... 572 210. Spontaneous amputation in gangrene of right foot and left leg from plastic arteritis ........ 578 211. Temperature table in a case of pyaemia following primary amputation of the foot ........ 608 212. Temperature table in a rapidly fiital case of pyaemia following a com¬ pound and comminuted fracture of the bones of the leg . . 609 LIST OF ILLUSTRATIONS TO VOL, I. xxiii FIG. , 213. Contents of sebaceous tumor: cliolesterine, fatty and granular matters 214. Horn on nose of a child ....... 215. Ulcerated encysted tumor of scalp ..... 21G. Structure of fibroid tumor ....... 217. Pendulous fibro-cellular tumor ...... 218. Myxoma from parotid ....... 219. Fusiform and oat-shaped cells from myeloid tumor 220. Recurrent malignant nasal polypus; spindle-cells. Myeloid sarcoma. 220 diameters . . . . . . . 221. Myeloid plates or plate-like cells from a tumor of the lower end of the femur ......... 222. Fibro-plastic tumor springing from the scapula . . . . 223. Cells from fibro-plastic tumor of scapula : first recurrence 224. Microscopic characters of the tumor in its second recurrence. Multi- nucleated myeloid cells ....... %/ 225. Myeloid tumor of radius ....... 220. Myeloid tumor of the metacarpal bones of the index and middle fingers. Successful removal of those bones and fingers .... 227. Structure of enchondroma ...... 228. Large enchondroma of index finger . . . . . 229. Ordinary enchondroma of finger ...... 230. Scirrhus of breast; showing cells and fibres .... 231. Scraping from scirrhus of breast ...... 232. Cells from encephaloid of tongue (rapidly recurring). Magnified 300 diameters ..... . . . . 233. Cells from scirrhus of breast (rapidly recurring). Magnified 300 dia¬ meters ......... 234. Scirrhus of breast, hardened in chromic acid; showing stroma 235. Epithelioma of the lower lip. Male, about 21 . 230. Section of an epithelioma of the cheek, showing the formation of epi¬ thelial cells within the substance of the true skin 237. Cells from epithelial cancer of lower lip . 238. Cells from chimney-sweep’s cancer ..... 239. Concentric globes of epithelioma ...... 240. Steel chain ecraseur ....... 241. Ecraseur applied ........ 242. Scrofulous ulcer of leg ....... 243. Scrofulous disease of arm and finger . . . . . 244. Diagram from Virchow, of development of tubercle from connective tissue in the pleura, showing transition from corpuscles of that tissue up to the production of tubercle granules. The cells in the middle are undergoing fatt}’- degeneration. 300 diameters 245. Syphilitic temporary teeth ...... 240. Syphilitic permanent teeth ...... 247. Syphilitic onychia ........ 248. Hypertrophy and deformity of toe-nail . . . . . 249. Cells from lupus of the neck. Magnified about 1200 diameters 250. Rodent ulcer: perforation of skull and exposure of dura mater 251. Cancerous ulcer of the leg ...... 252. Neuroma with nervous filaments spread out over tumor 253. Application of pins to varicose veins . ... . 254. Syringe for injecting mevi ...... 255. Diagram of the application of nsevus-needles . . . . 250. Diagram of nsevus tied ....... 257. Diagram of ligature of flat and elongated naevus 258. Diagram of flat and elongated nsevus tied . . . . 259. Nsevus of lower lip; front view ...... 200. Nsevus of lower lip; side view . . . . ' . ’ 201. Large nsevus of upper lip : front view' . . . . . 202. Large nsevus of upper lip: side view . . . . . 203. Nsevus of tongue ........ PAGF. 028 029 029 037 033 039 040 040 041 041 042 042 042 042 044 044 044 040 040 047 048 048 008 008 009 009 009 071 071 070 077 • 078 723 724 727 728 730 733 737 742 707 771 i iO r^r*' i 4 774 ^74 I *■ 4 I i 777 778 778 4 ii ■r;.p •| -ti' ' •' iV I ■'•.■'« v.m ■,'^, iU;'. ■ ^^v?r; ■ ‘' v^v m ■ f I f ' ♦* ‘'dj*-*#** *4 H. ..'«i. , rfp V- , -fi M • .. • 't;.^.''iai^- ..1. r:ta»a i ^ i -ow '■ ^ •»' ^- • ::»>'•■ V * .V •' • ill' V.W ‘' -aHk '•'W k.-'/ '-'i^-.., '■ '■'■Itl ■ *,<»<... :5 i ^ ■■ 4k , H'Wiflv,, —■ ■" _»*» ' i*” .V^ •fn. -f.4 S\ . a ’ ' • *M. . - r ■KX ■ *™i| -' J-lfTw.tff’ ^'-'M-Ati . 'mSt '-' ft *r' ^*y': '”*3^' ’3 ' f !& • : » • 4 *1 . '• V * I • « ffli tk r- « 1 ■ tW"' , .^vWiF ; .V I.. i . ,., W im '•'^4 r:iI^.J4 If .iXf v>- ‘- ‘ »*'''‘“S^.'' ■ .... ■ "^'Ijk K}j[ ■V *iv'‘. i’ > ,.v*'N . ' T'''>S. ' / '^ ' ■'' . -.1. I* -'^ Ti' <»*' ^ »t*. 1 I* I f ■ ! • . ■' '®■ k;■■■ ■:.''’l£.. •;-.'':J^? '‘'1 i‘V ■ ''-.'.I ' ■' i - ■ . - .fl__ ^' •: . '■■'>-< ti* ' ■• ’^' :y' 'W;./,' .;•' i ^ 'i'HJC 'V','. I '■< ■ t"fc|>' ■'■'• ■,,' ■. •;" ' '>" 5 i ii^3E^ftA t k. [Lk ' ^ ft I -«>« \ ' c ‘' ^ '41 ‘l/i' ., ' ♦ ■ • ' V* ^ _iv;-; A' k.'H t«- ■’ « < • r ' Vl J I A' I THE SCIENCE AND ART OF SURGERY. DIYISION FIRST. FIRST PRINCIPLES. CHAPTER I. GENERAL CONSIDERATIONS ON OPERATIONS. By a Surgical Operation is meant a Manual or Mechanical Process undertaken by the Surgeon for the remedy of Deformity, congenital or acquired, or for the cure or relief of a patient suffering from the effects of Injury or Disease, that are incurable by constitutional or ordinary local treatment, or in which such treatment would be too slow in effecting the desired result. A Surgical Operation may be necessary for the following objects:— 1. For Remedying or Removing Congenital Defects and Malforma¬ tions : as Harelip, Clubfoot, or Supernumerary Fingers or Toes. 2. For Remedying Acquired Defects and Deformities: as in the Clo¬ sure of Fistulse, the Restoration of Lost Parts, and the Correction of Distortions of the Limbs. 3. For the Removal of Foreign Substances from the Body: as in the Extraction of a Bullet or a Calculus. 4. For the Repair of the Effects of Dijuries : as in the treatment of certain Fractures and Dislocations. 6. For the Removal of Parts that have been so disorganized by the effects of Injury that their vitalit}^ is lost, or that their continued con¬ nection with the rest of the body would be a source of danger: as in Amputation for Frost-bite or Mangled Limbs. 6. For the Removal of Diseased Structures that interfere with the utility of an organ or part: as in the Extraction of a Cataract. t. For the Removal of Diseased Sti'uctures that seriously inconveni¬ ence the patient or that remotely threaten life: as in the Extirpation of Tumors, Simple or Malignant. 8. For Rescuing a Patient from Immediate and Inevitable Death: as in Tying a Bleeding Artery, Opening the Windpipe in Laryngeal Ob¬ structions, Relieving an Over-distended Bladder, or Dividing the Stric¬ ture in Strangulated Hernia. Manual dexterity is necessarily of the first advantage in the perform¬ ance of any operation, and the Surgeon should diligently endeavor to VOL. I _2 18 GENERAL REMARKS ON OPERATIONS. acquire the Art of using his instruments "with neatness, with rapiclit}*, and with certainty’. In many cases of minor moment, no other requisite is needed by the Surgeon than this. But it "would, indeed, be a fatal error to suppose that, in the majority of cases requiring surgical inter¬ ference, this is the onl}^ or indeed the chief requirement on the part of the operator. Manual dexterity must not be mistaken for surgical skill; and, desirable as it doubtless ma}^ be to be able to remove a limb, or to cut out a stone, with rapidity—important, in a word, as it is to become a dexterous operator—it is of far greater importance to become a suc¬ cessful Surgeon. The object of every operation is the removal of some condition that either threatens life or interferes with the comfort and utility of existence; and the more certainly a Surgeon can accomplish this object, the better will he do his duty to his patients, and the more successful will he be in his practice. Success then, in the result of an operation, whether that result be the preservation of life or the removal of a source of discomfort, is the thing to aim at. To this, dexterity and rapidity in operating are in a high degree conducive; but there are various other considerations equall^^or still more necessary, the solution of which can only be afforded by an intimate general acquaintance with the Science of Surgery and of Medicine. The Diagnosis of the nature of the local disease, and of the extent of its connections, has to be made ; lurking visceral affections must be detected and, if possible, removed. The Constitution of the patient must be prepared; he must, as far as possible, be placed in those hygienic conditions which are most favorable to recovery ; the best time for the performance of the operation must be seized ; and, after its completion, the general health must be attended to in such a way as sliall best carry the patient through the difficulties he has to encounter, and any sequelm or complications that arise must be subjected to appropriate treatment. These, as well as the simple per¬ formance of the operation, are the duties of the Surgeon ; and on the manner in which they are performed, as much as, or even perliaps more than on the mere manual dexterity displa 3 ’ed in the operation itself, will the fate of the patient depend. It is well knowui that the result of ope¬ rations differs much in the practice of different Surgeons of acknowledged dexterity’; and this variation in the proportionate number of recoveries cannot be accounted for by any difference in the degree of manual skill displayed in the operation itself, but must rather be sought in the greater attention that is paid b}^ some Surgeons to the constitutional treatment of their patients before and after operation, and to their more perfect :acquaintance with the general science and practice of surgery. Indeed, :success in operative surgeiy depends gTeatly upon tlie selection of proper «cases. The practice of operating in notoriously hopeless cases witli the vdew of giving the patient what is called a last chance, is much to be deprecated, and should never be followed. It is by operating in such circumstances, especially’ in cancerous diseases, that much discredit has resnlted to Surgery; for in a great number of instances the patient’s death is hastened by the procedure, which, instead of giving him a last chaime, only’ causes him to be despatched sooner than would otherwise have happened. It may truly be said that a great surgical operation, in its conception, its performance, and its completion, tests the operator’s medical knowledge as much and in as varied a manner as it taxes his mannal skill; and that, taken as a whole, it is the highest development of the medical art. Caiaditions Influencing the Success of Operations. —The cir- cnnistainces that mainly’ influence the result of an operation, so far as the INFLUENCE OF GENERAL HEALTH. 19 reeoveiy of the patient is concerned, ma}" be arranged under three heads : 1. Those that are connected with the State of the PatienVs General Health at the time of its performance; 2. The Hygienic Conditions by which he is surrounded after it is done; and 3. The Special Dangers connected with the operation itself. 1. The condition of a patient that principal!}^ determines the result of an operation is the State of his General Health. Indeed, success is influ¬ enced far more by the state of the patient’s constitution than by the severity of an operation, or by the mechanical dexteritj^ with which the Surgeon performs it. Veiy often we see a patient carried off by fatal disease supervening on some extremelj' trifling operation (such as the removal of a small encysted tumor), which in itself ought in no way to endanger life were it not that the patient’s constitution was at the time of its performance in so unhealthy a state that the slightest exciting cause was suflEicient to call into activit}’’ fatal disease. So, also, it is no uncommon circumstance to see one patient sink after the most dexter- ousl}^ performed operation for hernia, stone, the ligature of an arteiy, etc.^ owing to some morbid condition of the blood or of the S 3 "stem that dis¬ poses to low or diffuse inflammation; whilst another ma}' possibly’ make the most remarkable and rapid reeoveiy after he has been mutilated with but little skill. Independenth" of actual organic disease, there are certain conditions of the bod}" with respect to the condition of the nervous S 3 'stem, the circulation, and the general ph 3 "sical state, that exercise an injurious influence. Thus, persons of an irritable and anxious mind do not bear operations so well as those of a more tranquil mental constitu¬ tion. Those also of a feeble and irritable habit of bod}", especially nervous and ly’sterical women, with little strength of circulation, cannot bear up against severe surgical procedures ; being apt to become de¬ pressed and exhausted, and to sink without rall 3 "ing. Persons who are overloaded with fat are not good subjects for surgical operations. In them the circulation is iisuall}" feeble ; the wound heals slowh" and is apt to become slough}"; and intercurrent disease of a low type often sets in. Short of actual structural disease of important organs, as the lungs, heart, or kidneys, I know no condition more unfavorable to success after operations than premature or excessive obesity. An individual of a sound constitution, that has never been impaired by excesses of any kind, whose habits have been temperate and sober, whose diet has been sufficient and of good quality, whose mind has never been overstrained by the anxieties of business or the labors of a professional life, and whose existence has been spent in rural occupations and in the pure air of the country, is necessarily placed in a far more favorable position to bear the effects of any mutilation, whether it be the result of injury, or be inflicted by tlie Surgeon’s knife, than the man of active and unceasing business avocations or professional habits, whose nervous system is exhausted by his anxious labors; and far more so than the poor inhabitant of a large and densely peopled town, who has from earliest childhood inhaled an impure and fetid atmosphere, whose scanty diet has consisted of the refuse of the shops, or the semi-decomposed offal of the stalls, and whose nervous system has been irritated and at the same time exhausted in the daily struggle for a precarious livelihood, or over-stimulated by habitual excesses in strong drinks, by which he has hoped to purchase temporary forgetfulness of the cares of a sordid life. Though individuals with such different antecedents be placed under exactly the same hygienic circumstances after the performance of an operation, yet the results will probably be very dissimilar, influenced as 20 GENERAL REMARKS ON OPERATIONS. they must be by their past rather than by their present condition. In the one case, the inflammation resulting from the incision, and requisite for the cure of the wound, will not overstep the normal degree necessary for the healing process. In the other it maj'' not attain to this, but, assuming a low and diffuse form, may terminate in some of those secon¬ dary affections which will presenth^ be adverted to as occasioning death under unfavorablejrygienic conditions. Besides the general state of the patient’s health, the Condition of Im¬ portant Organs must be taken into consideration. The state of the patient’s Heart should be carefully looked to before an operation is undertaken. Valvular disease of this organ, if early or slight, need not be an obstacle to most operations, especially those of expediency. But fatty degeneration of the heart, as indicated by its feeble action, by irregularitj’ and w^ant of power in the circulation, by breathlessness, and by a distinctly marked arcus senilis, should make the Surgeon careful in undertaking any operation attended with much loss of blood or shock to the nervous system. Such a condition of heart is liable to occasion great depression of strength, syncope and death—often sudden—some da^^s after the operation. It need not, however, be a bar to its performance, if the disease for which it is to be practised w’ould otherwise be fatal. Disease of the Lungs, of a phthisical character, when active or advanced, is incompatible with the success of an operation; but under certain circumstances, as will be explained wiien speaking of diseases of the joints and flstula in ano,an operation is justifiable and proper, even though the patient be consumptive. If the Liver be diseased organicall}", if it be in a state of amyloid degeneration, or affected by cirrhosis, and more especiall}^ if any ascitic symptoms haA^e supervened, no operation but for the relief of disease that instantly threatens life should be undertaken. Perhaps the most serious constitutional affection, and the one that more than any other militates against the success of an operation, is a diseased state of the Kidneys, wdiether it assume the form of albuminuria or of diabetes ; in these conditions, the local inflammatory action that is set up is apt to run into a low, diffuse, and sloughing form, and this is especially the case in all operations about the genito-urinaiy organs. The contamination of the patient’s system by Malignant Disease must alwa 3 "S prevent our operating, as a speedy return of the affection will most certainly take place. And, lastly, no operation, save of the most urgent necessit}", and to rescue the patient from immediate death, as for the suppression of arterial hemorrhage, should‘ever be performed whilst he is laboring under P^^aemia, Septaemia, Eiysipelas, Phlebitis, or an}^ Diff'use Inflammation; and even during the epidemic prevalence of these affections, operations that are not of immediate necessit}^ should be post¬ poned until a more favorable season. Operations in very old people, if severe and attended by much shock to the system, are commonly fatal; amputations in individuals above the age of seventy", are veiy rarel}'' successful. 2. The result of an operation, though greatl}" dependent on the state of the patient’s constitution at the time of its performance, is also mate¬ rially influenced hy the Hygienic Conditions to which he is afterwards subjected. The conditions wdiich chiefl}^ militate against the success of an operation, are bad or insufficient diet, the exposure of the patient to the influence of contagious miasmata, and more particular!}' the over¬ crowding of the sick and wounded, Avhich gives rise to an impure state of the atmosphere, productive of the most fatal consequences. OVERCROWDING TO BE AVOIDED. 21 The proper regulation of the patient’s diet before and after an opera¬ tion is of great consequence. On this point it is impossible to lay clown any very definite rule, as much depends not only on the patient’s previous habits of life, but on the nature of the operation itself; and, as this sub¬ ject will be discussed at the end of the Chapter, it need not detain us here. It is not, however, often that in civil practice the insufficient quantity or the bad quality of the patient’s food, with which he is sup¬ plied after the performance, influences materially the result of an opera¬ tion. Blit in military and naval practice the case is far diflerent'. The soldier or the sailor on active service is often exposed to serious injuries that necessitate the more important operations at a time when his con¬ stitutional powers have already been broken down by scurvy, dysenteiy, or some other similar affection, resulting not so much from the deficient quantity as from the unwholesome character of the food with which alone he can be supplied. And after the operation his only available nutri¬ ment may be of the coarsest character, possibly salted, and imperfectly cooked. In such circumstances operation-wounds do not heal, or they assume a peculiar gangrenous character; or the patient sinks from ulce¬ ration of the intestinal mucous membrane. The mortality of operations becomes enormously increased ; and there can be little doubt that thou¬ sands of deaths which have occurred in wars between the most civil¬ ized nations and the best appointed armies may be attributed to these causes. The exposure of a patient after an operation to contagious emanations from other sick or wounded patients, may be attended b^^ the most fatal consequences. Whenever it is practicable, every case of pyiemia, erysipelas, inflamed absorbents or veins, or hospital gangrene, should be rigorously excluded from the same ward or room in which other patients with operation-wounds happen to be lying; and, if possible, the same nurses, dressers, or surgeons should not be allowed to go from the infected to the healthy, nor should the same dressings or sponges be ever used for both. Every Hospital Surgeon must have had abundant occasion to deplore many deaths after operation, arising from preventable causes due to want of attention to these precautions. Perhaps there is no hygienic condition of greater importance, so far as the results of operations are concerned, than the avoidance of the over¬ crowding of operation-cases or of injured persons in one ward or build¬ ing ; more particularly if the wounds be in a suppurating state. In these circumstances, the atmosphere becomes loaded with animal exhalations in a state of putrescence or fermentation. These are either absorbed by the lungs and skin, or the pulmonary and cutaneous surfaces are unable to set free their excreta in an atmosphere already surcharged ; the blood becomes thereby vitiated, and low, diffuse, or erysipelatous inflammations of all kinds, with p 3 " 8 emia, septmmia, or sloughing phagedsena, are the necessaiy consequences. In fact, these diseases ma^^, if the term is allowable, be manufactured in any hospital or house, however clean and well situated, by the accumulation within it of too large a number of patients suffering from suppurative fever. The two great conditions to be attended to in the prevention of overcrowding are : (1) Sufficient cubic space for each patient; and (2) An efficient system of ventilation. Both conditions are equally necessary. The space afforded to each patient in the surgical ward of an hospital where patients with suppu¬ rating wounds are mixed with others suffering from such injuries as simple fractures, unattended by breach of surface, should be at least 1500 cubic feet, and this should be changed by" ventilation, once, if not 22 GENERAL REMARKS ON OPERATIONS. twice, in the hour. If the proportion of simple cases be great, less than this may be safe ; but if the majorit}" of the patients have suppurating wounds, more space, as much even as 2000 cubic feet, should, if possible, be allowed. Whenever we have had an outbreak of the low surgical inflammations—of eiysipelas, sloughing phagedoena, or p3"8emia—in the wards at Universit}' College Hospital, it has been owing to the accidental and, perhaps, unavoidable accumulation of a large number of serious injuries or of operation-cases in one ward, so that the cubic space for patient’s has become reduced materially below the figures above stated. Xot only, however, is space required, but change of air^ by proper ven¬ tilation^ is equally needful. For, however large the cubic space for patients, the air, if not changed rapidly enough, soon becomes loaded with animal exhalations, and highlv insalubrious. Hence care should be taken that a free current of pure air through the ward be maintained day and night. It is from want of this precaution, during night espe- ciall}', that much mischief often results. The importance of maintaining efficient ventilation during night, and the little danger to be apprehended from the admission of cold night air, have been so forcibly pointed out by M iss Nightingale in her Notes on Nursing^ and are now so universally admitted, that I need not do more than to add the testimony of m3" expe¬ rience to the truth of her observations. In cold weather, also, there is so great a disposition on the part of nurses and patients to shut up wards and rooms, that the air becomes close, oppressive, and contami¬ nated ; and hence it is that the eiysipelatous and miasmatic diseases are so rife during winter and earh" spring. The “ East Wind” is commonly accused of being the cause of these ; and no doubt it is so, but onl3" indirectl}", b}- causing windows and doors to be shut, so as to exclude the cold that usuall}" accompanies that wind, and thus rendering the atmosphere impure. It is impossible to over-estimate the importance of a free supplj- of pure air in lessening the mortalit}" after operations, not onl}" in hospitals, but equall}" in private dwellings. Hence it is that operations are more successful when performed on the health}^ inhabi¬ tants of the countiy than on those whose lives have been spent in the close and vitiated atmospheres of towns. And to the same cause ma}" be ascribed the exemption of small countiy or “ Cottage Hospitals” from those evil influences that infect the best constructed establishments of a similar kind situated iu large towns. Hence, also, the fact that has so often been observed in militaiy practice, and which the recent Franco- Prussian War has brought into strong relief—that those wounded fare best who are treated in open huts or tents, whilst those who are placed in the apparenth’ more favorable conditions afforded b}" regular houses become decimated b}" those scourges of militaiy surgical practice, P3"8emia and hospital gangrene. It is therefore obvious, that the performance of operations in close and ill-ventilated rooms, or in houses situated in over¬ crowded, badl}" drained neighborhoods, should, as far as possible, be avoided, and the patient placed in more favorable h3"gienic conditions. The mortalit}* arising from inattention to these various hygienic con¬ ditions is not a necessit}* of the operation, but rises or falls according as the circumstances in which the patient is placed depart more or less widel3" from those conditions that are necessaiy to the maintenance of health. It is 1)3’ the induction of p3’8emia and of the er3’sipelatous in¬ flammations, with fever of a low t3’pe, that the neglect of the hygienic conditions of operated patients destroys life. The prevalence of these diseases in a localit3’ or an institution is the measure of, and in direct CAUSES OF DEATH AFTER OPERATION. 23 proportion to, the deteriorated constitutions of the inhabitants, and the breach of sanitary laws. 3. The Special Conditions directly excited by the Operation itself (though predisposed to by the circumstances that we have just been considering) and which commonly lead to a fatal result, of which they are the immediate occasion, are the following: Shock, Exhaustion, Hemorrhage, Gangrene, Tetanus, Internal Inflammation of an acute kind, PY[emia, and the various Low, Diffuse, and Erysipelatous Inflam¬ mations. These causes of death are so various, and comprise so many distinct diseases, that I shall do little more here than mention them ; referring the reader to the different Chapters in the Bodj^ of the Work, in which each is specially treated. The Shock of an Operation may prove fatal in various ways : from the severity of the mutilation, as in a case of double amputation ; from the nervous centres being implicated, as in the removal from the face of large tumors that have connections with the base of the skull; from fear, or from the state of nervous depression, into which the patient has pre¬ viously fallen, causing liim to feel the influence of an operation dispro¬ portionately to its severity. These various effects of shock have, however, been much lessened since aiifesthetics have been generally administered in operative surgery. Anesthesia, however, does not remove the physical impression produced on the system b}’’ a severe mutilation; hence the influence of a serious and prolonged operation is still manifested in the production of shock, of collapse, and of slow recovery, even though the patient have suffered no actual pain. Certain operations appear to exercise a peculiar depressing effect on the nervous system, even though no pain be experienced. Thus, in castration, at the moment of the division of the spermatic cord, I have often observed the pulse to sink markedly, even though the patient have been fully anaesthetised. So much is this the case, that it is well at that moment to suspend the administration of the chloroform. Exhaustion^v^ithont an}’’tangible local or constitutional disease, is an occasional cause of death after severe operations ; more particularly in delicate females, in feeble or debilitated subjects, or in those who have lost much blood. Hemorrhage.^ if very copious, may destroy the patient by inducing syncope that may be immediately fatal; or by increasing the influence of the shock so that he cannot rally ; or it may be followed by serious after-consequences, such as the supervention of hemorrhagic or irrita¬ tive fever, and a disposition to the occurrence of low and erysipelatous inflammations. It is in these secondary and indirect effects that the great danger of excessive hemorrhage lies. Patients who have lost much blood make slow recoveries, often interrupted by intercurrent diseases; and not unfrequently die at the end of two or three weeks, from some asthenic visceral complication. In fact, it is in this way, rather than from its immediately dangerous consequences, that the loss of a large quantity of blood at an operation proves injurious to the patient. When hemorrhage occurs a few hours, or a day or two, after an opera¬ tion, it usually proceeds from imperfect ligature of the vessels, or from arteries bleeding after the setting-in of reaction, which had not furnished blood whilst the patient was under the influence of the shock of opera¬ tion. On recovery from chloroform also, it not unfrequently happens that arteries begin to spout, which yielded little or no blood whilst the patient was in a state of anesthesia. In these circumstances, hemor¬ rhage is of far less moment, and less frequently fatal, than when it 24: GENERAL REMARKS ON OPERATIONS. occurs at a later period, in consequence of some morbid condition of the wound or s^-stem, and usuall 3 ^ in association with a t^q^hoid state, b}’’ which the proper formation of plastic matter is interfered with. During the performance of an operation, hemorrhage should, as much as possible, be prevented ; the operation itself is a cause of depression, and an\" great loss of blood not onl}’ seriously’ aggravates this, but dis¬ poses to the after-occurrence of pj’mmia and low inflammations. The Performance of an Operation during the existence of any Acute Inflammation^ as of a joint, for instance, is alwa^^s attended l\y great danger: more especiall}", if the disease be an inflammation of a low form, as phlebitis or erysipelas. So great is the danger of performing an}’-, even the most trifling operations, in cases of this kind, that the}- never should be undertaken, except such—the ligature of a bleeding vessel for instance—as may be imperatively required for the immediate preser¬ vation of life. The danger in these cases is from the supervention of pyaemia. This appears to be occasioned by the blood, in such cases, being loaded with a quantity of effete materials, which run into a state of disorganization under the influence of the new inflammatory action set up by the operation. Gangrene is not a common cause of death after operations. In some cases of amputation, however, it may occur in the stump; after the operation for strangulated hernia, in consequence of the constriction of the gut; or in any wound^ in its contagious form of sloughing phagedaena. Tetanus but rarely occasions death after operations in this country. When it does occur, it is more frequently after the lesser than after the greater operations that it develops itself. Internal Inflammations of an acute and active character may carry off the patient after an operation in two ways. Inflammation of this kind may have existed antecedently to the operation, being the disease for which it is performed ; and, being unchecked by the operation, may continue its course and destroy life. Thus, when a child dies after tra¬ cheotomy for croup, death is not in general occasioned by the operation, but by the extension of the disease for which it has been performed. Or the inflammation may be the necessary and direct consequence of the operation; as when peritonitis occurs after the operation for strangu¬ lated hernia, or arachnitis after the skull has been trephined. But it is not by the action of any of these direct results that an operation usually proves fatal. In the great majority of instances, death is occasioned in a more indirect manner by the development of pyaemia, or of some of those low and erysipelatous inflammations which are allied to it, and to which a neglect of hygienic laws acts as a powerful predisposing cause. Pydemia \s> certainly the most frequent cause of death after operations, more particularly in large towns. It is especially and directly predis¬ posed to by the neglect of hygienic laws by the patient previously to the operation, and by the unfavorable sanitary conditions by which he may be surrounded after its performance. Closely allied to pymmia, frequently coexisting with it, having the same predisposing causes, and associated with febrile disturbance of an asthenic type are the various low and diffuse inflanimation assuming the form of erysipelas, of phlebitis, or of inflammation of the absorbents, which are the dread of surgeons and the scourge of hospitals. It is to pyaemia, and to these various allied erysipelatous and low inflammations, with their attendant asthenic constitutional disturbance, that at least three-fourths of the deaths after operations are due. It is in the production of these PREPARATION FOR OPERATION. 25 diseases that an impure blood, loaded with effete materials retained through habitual disregard of the ordinary rules of health or through defective elimination by the kidne 3 ’s and skin, acts as a potent predis¬ posing cause, requiring but some injuiy or wound to call into activity' a most dangerous amount of local inflammation and of constitutional clis- turbance. In these circumstances, it is not the extent or size of the w’ound that determines the dangerous results. The mere fact of a breach of surface, however trivial, is sufficient to excite these morbid processes, the materials for which have been previonsl}’stored up in the system. In such conditions of the s}’stem,the amputation of a toe ma^" be as fatal as that of the thigh, or the removal of a small scalp-atheroma as the ablation of the breast; the onl}" additional danger essentially" connected with the greater operations being the increased risk from shock and hemorrhage. Diphtheritic Inflammation may- develop in a wound with or without concomitant throat affection. It maybe developed by direct contagion, or under the influence of those local epidemics or constitutional influences that cause diphtheria to appear in the fauces. When a wound becomes affected in this way’, the edges and the integument for some little dis¬ tance around are swollen, brawny-, and of a deep red color; the surface of the wound is covered with a graydsh-white exudation which cannot be cleaned off; the skin immediately-contiguous to the wound also becomes besmeared with tenacious creamy-dooking exudation matter; and febrile sy-mptoms of a low tyqoe develop themselves. Preparation for Operation. —The Surgeon, being convinced of the necessity of having recourse to operation, should fully and unreservedly lay before his patient the state of the case, and, if necessary", give the reasons that render an operation imperative, in order to obtain his consent and that of his family-. In the event of the })atient refusing to submit, what course should the Surgeon pursue? In this he must be guided partly by the nature of the proposed operation ; and partly- by the state of the patient, and his capability^ of forming a correct judgment of his case. If the operation be one of expediency, merely^ for the relief of an infir¬ mity or the removal of an ailment which does not directly jeopardize life, most certainly no Surgeon would think of undertaking it without the full consent of his patient. If, on the other hand, it be an operation that is imperatively" necessary for the preservation of life, in which the delay- of a few minutes or hours may- be fatal to the patient, as in the case of the proposed ligature of a bleeding artery, or the relief of a strangulated hernia, and where the patient, unaw’are of, or incapable of being made to understand, the necessity'' for immediate action, is nn- wdlling to assent to the proposal, the Surgeon will truly be placed in a dilemma of anxious responsibility; between allowing the patient to fall a sacrifice to his ignorance or timidity-, and attempting, perhaps unsuc¬ cessfully-, to rescue him from inevitable death against his own consent. I believe the proper course for the Surgeon to pursue under such circum¬ stances, is to judge for the patient in a matter on which he is clearly unable to form an opinion, and to compel him, so far as practicable, to submit to the necessary steps for the preservation of his life, or to put him under chloroform, and, when he is anesthetized, to perform any operation that may be necessary-. In the event of the patient being insensible, as after an injury- of the head, the Surgeon must necessarily take upon himself to act as the case requires. Children cannot be con¬ sidered capable of giving an opinion as to the propriety of an operation ; the-consent of the parents is here necessary-, and quite sufficient; and, 26 GEXEEAL REMARKS ON OPERATIONS. in their absence, the case being an urgent one, the Surgeon must stand in loco parentis^ and take all responsibilit}^ upon himself. These points then having been determined, the patient should, if pos¬ sible, be Prepared for the Operation. In a great number of cases re¬ quiring operation, as in strangulated hernia, bad compound fracture, etc., no time is allowed for preparation, but the Surgeon must at once submit the patient to the knife, whatever the state of his constitution may be. But in the more chronic cases, time is given for improving the constitu¬ tion. This preparation must not consist in any routine s 3 'Stem of purging and starving, which is ill calculated to support the constitution against the call that will be made upon its powers; nor, on the other hand, in a tonic or stimulating regimen, which maj^ produce fever and irritate the constitution ; but in adapting our means to the condition of the patient and the nature of the operation to be performed. The ten- denc}" to eiysipelas, pymmia, and low and diffuse inflammations gener¬ ally', is materially' lessened by' supporting the patient’s strength, by means of a nutritious diet, previously^ to the performance of the opera¬ tion. Indeed, in many of the more severe cases of compound fracture and disease of the joints, it is only by^ the use of a nutritious diet, and by' the administration of tonics, quinine, or iron, and stimulants, often in large quantities, that the patient can be brought into a condition to bear the shock and consequent depression of the operation. This is more particularly' the case with hospital patients of bad constitution, who have met with serious accidents, attended by much suppuration and irritative fever. In the more chronic cases, the time should be seized for the operation when the secretions are free, the tongue clean, and the action of the skin and kidney's in a healthy' state; and, above all, the mind should be kept tranquil and hopeful, being allowed to dwell as little as possible upon the impending event. In many opera¬ tions, as those on the rectum and urinary organs, or in those of a plastic character, special modes of preparation are required, which will be dis¬ cussed when we come to treat of the operations in detail. The Immediate Preparations for the operation should always be su¬ perintended by'the Surgeon himself. He must see that the table is solid, and of a convenient height, well covered with blankets, and provided with pillows; and that the light of the room is good. There must be a sufficient supply'of sponges and of basins, with hot and cold water; and, if the operation be likely to be attended by' much hemorrhage, a tray' filled with sand or sawdust should be provided, in order to catch the blood. The Surgeon must then look over his instruments, com¬ paring them, if the operation be complicated, with a list previously’’ made out; he must see that they' are arranged in the order in which they' are wanted, and properly' covered with a towel. Much of the successful performance of an operation depends on the attention and steadiness of the assistants. Of these there should be enough, but not too many'. In all capital operations three or four will be required; one for the ad¬ ministration of the anmsthetic, another to command the artery', a third immediately^ to assist the Surgeon, and the fourth to hand sponges, in¬ struments, etc. The duties of the assistants should be performed in silence, and each man must carefully’ attend to his own business, and not neglect this, as is too often done, in his anxiety to crane over and see what the Surgeon is about. There should be no unnecessary' talking when once the patient is on the table; the Surgeon’s directions ought to be conveyed by a brief word or two, by' a look, or by' a sign with the hand. ANAESTHETICS IN SURGERY. 27 The Surgeon himself must always feel the heavy responsibility that hangs over him during the performance of a great operation—“at that moment when,” as Dr. Grant has elegantly said, “ Death everywhere surrounds his knife as he is endeavoring to convey all his knowledge to its point.” But having carefully considered each successive step of the operation, provided for every emergency that can by any possibility arise in the course of it, and trusting in Him, from whom all knowdedge is derived, to strengthen his judgment and guide his hand aright, he will proceed to the performance of his duty with self-reliance, and in the full confidence of being able to effect all that Art can accomplish. Employment of Anaesthaetics. — It is reasonable to believe that the prev'ention of pain in surgical operations has been an object of so¬ licitude to Surgeon as well as to patient from the earliest ages: and there can be little doubt that narcotics of various kinds have at different times been employed with this view. But the effect of these was so un¬ certain—their after-consequences perhaps so injurious—that no perma¬ nent reliance was placed upon them. The first endeavor to induce anmsthesia by the inhalation of vapors is stated to have been made in the thirteenth centuiy by Theodoric, who recommended that a “ Spongia Somnifera,” impregnated with spirituous extracts of various narcotic substances, should be held to the nostrils till sleep was induced; and that after the operation the patient should be roused by tlie use of vine¬ gar or fenugreek. It was not, however, till the commencement of this century that any serious attempts were made in this direction. The discovery of the remarkable properties exercised on the nervous system by the inhalation of nitrous oxide, then led Sir Humphry Davy and others to entertain hopes that it might be used as a means of relieving pain during surgical operations. Experiments w^ere made wdtli the gas with this view, but they did not prove altogether satisfactory, and it was abandoned, except as a means of amusement. It is needless to do more than allude to such means as the compression of the nerves of the limb, as recommended by Moore—the employment of excessive venesection, as adopted by Wardrop—or the production of insensibilit}^ by mesmerism by Esdaile and others. These means of inducing anaesthesia were either inefficient, dangerous, or chimerical. It was not until 1844 that a serious attempt was again made to introduce insensibility during operations by inhalation: and to the Americans is undoubtedly due the honor of having established the practice of Anaesthesia in Surgery. Tn that 3 "ear Horace Wells, a dentist of Hartford, Connecticut, inhaled the nitrous oxide gas with a view of rendering himself insensible during the extraction of a tooth; and, finding the experiment succeed, repeated it on sever'al of Iris patients. Its success was not, however, permanent; and having failed in several cases, he seems to have given up the attempt. In 1846 Dr. Morton, a dentist, and a pupil of Wells, used the vapor of ether instead of the rrrtrous oxide gas; and, having succeeded in extracting several teeth painlessly, applied to the authorities of the Massachusetts General Hospital at Boston for permission to administer it to a man from whom Dr. J. C. Warren was about to remove a tumor of the neck. The result was most successful. The news of this great discovery was immediately sent to England, wher-e the first operations on patients anaesthetized by the inhalations of tire vapor of ether, were performed at the Uni¬ versity College Hospital by* Liston, who amputated a thigh and tore out an ingrowing toe-nail without any suffering to the patient. This was on December 22, 1846; and from that time the use of anresthetics 28 GENEEAL EEMARKS ON OPERATIONS. lias been established in surgical practice in every civilized countiy in the world. For more than a year, sulphuric ether was the only agent habitually used for inducing aniEsthesia. But during the whole of this period maii}^ professional men w^ere busy with experiments on the anmsthetic influence of various kinds of vapors; and in November 1847, Professor Simpson, of Edinburgh, published an account of the ansesthetic pro¬ perties of chloroform. In this country, this agent' soon came to be generally emplo 3 ’ed, although ether held its ground with the American surgeons, b}" man}' of whom it is preferred to chloroform at the present time. The employment of ansesthetics in surgery is undoubtedly one of the greatest boons ever conferred upon mankind. To the patient it is in¬ valuable in preventing the occurrence of pain, and to the Surgeon in relieving him from the distress of inflicting it. Anaesthesia is not, however, an unmixed good. Every agent by which it can be induced produces a powerful impression on the system, and may occasion dangerous consequences when too freely or carelessly given ; and even with every possible care, it appears certain that the inhalation of any anaesthetic agent is in some cases almost inevitably fatal. We cannot purchase immunity from suffering without incurring a certain degree of danger. There can, however, be little doubt tliat many of the deaths that have followed the inhalation of anaesthetics have resulted from want of knowledge or of due care on the part of the administrators. T'et, whatever precautions be taken, there is reason to fear that a fatal result must occasionally happen. This immediate risk, which is but very small, is more than counterbalanced by the immunity from other dangers during operations which used formerly to occur. There is, however, another question in relation to chloroform which deserves the most serious consideration on the part of the Surgeon ; viz.. Does it influence the rate of mortality after operations ? On this point there is conflicting testimony. Simpson has published statistics to show that the mortality after operations has lessened since the intro¬ duction of chloroform. J. Arnott, on the other hand, adduces figures to prove that it has materially increased, in amputation by 12, in lithotomy by as much as 28 per cent. I am inclined to believe that the rate of mortality has increased since the use of chloroform in operative surgery. But is this increase altogether due to any eflfect produced on the system by the inhalation of chloroform ? May it not, in some measure at least, be owing to operations being often performed in very doubtful or extreme cases, now that they can be done painlessly, when formerly the sulfering inflicted would have deterred the Surgeon from proposing, or the patient from acceding to, their performance ? A surgical operation w'as formerl}^, from the pain attending it, looked upon as a more serious affair than it is at the present day, and surgeons were not willing to inflict suflTering unless there were a good prospect of a successful issue. Now, however, that the most serious operations can be performed without any consciousness to suffering, the Surgeon, in his anxiety to give his patient a chance of life, may not unfrequently ope¬ rate for disease or injury that would otherwise necessarily and speedily be fatal, and which formerly would have been left w'ithout an attempt at relief. Making, however, all allowance for the extension of operative siu’gery to extreme cases that were formerly not thought to come within its range, I cannot but think that chloroform does exercise a noxious ADMINISTEATIOX OF CHLOEOFORM. 29 influence on the constitution, and does lessen the prospect of recovery in certain states of the system, more especially when the nervous power is enfeebled or the blood is in an unhealthy state. In such circumstances, the depressing influence of chloroform appears to me to act injuriously; the patient does not rally W’ell after the operation for which it is ad¬ ministered, and immunit}’’ from suffering is purchased by a lessened chance of recoveiy. Anseathesia by the Administration of Chloroform is best commenced before the patient leaves his bed. The chloroform should never be given but by a person accustomed to its use, and on whose capability the Surgeon has full reliance; as nothing embarrasses more, during an operation, than to have any doubt about the chloroform being properly administered. Chloroform may be administered in many different ways, either on lint or on a handkerchief, or througli an inhaler of some kind. The following is the way in which chloroform may most safely be given on lint or a handkerchief, without apparatus of any kind. On a j)iece of folded lint, about two inches square, and consisting of three doubles, about a drachm of chloroform is poured; and the lint is then held at a distance of about three inches from the nose of the patient, so as to permit a very free admixture of air w'ith the first few inhalations of the vapor. After the lapse of about half a minute, the lint is brought nearer to the patient’s nose, to within a distance of perhaps an inch, being never allowed to touch; at the same time a porous towel, not doubled, is lightly laid over the face of the patient and the hand of the operator, so as to prevent the escape of the chloroform-vapor, but not to interfere with the admission of air. During the whole time, it is the duty of the administrator to keep his hand on the pulse, to watch the breathing, and occasionally to examine the piq^ils of the patient. The method just described (giving chloroform on lint, the patient’s head being covered wMth a towel) answers well enough in most cases, but it affords no means of ascertaining the proportion of chloroform in the air which is being inhaled hy the patient. The administrator can judge only by the effects produced. There is a danger of the patient’s lungs being filled with a very strong mixture at the moment when the signs of an overdose are first perceived. In the most favorable circumstances it requires several respirations to replace the strong dose by fresh air; but if the patient happen to be in a rigid state, or his glottis be closed by spasm, considerable delay will occur, during which time, if the dose have not been strong enough to arrest the action of the heart, the blood is passing through the lungs and becoming further charged with chloroform. Various inhalers have been contrived for the purpose of regulating the proportion of chloroform with accuracy. The simplest kind con¬ sists of a mask covering the nose and mouth, with a box for sponge or blotting-paper on which the chloroform is poured, and with valves to prevent the expired air from passing through the chloroform-chamber. The objection to this form is, that it yields a very strong mixture at first; and, when the chloroform has half evaporated, the remainder is so cooled that it evaporates too slowlj^ to yield enough chloroform to insure the quietude of the patient, especiall 3 " if he should move his head about so as to get a small quantity of air between his face and the mouthpiece. Dr. Snow improved this apparatus by surrounding the chloroform chamber with water, and also making the upper valve movable, so that at the beginning of the inhalations only a portion of the inspired air 80 GEXEKAL REMAKES ON OPERATIONS. should pass over the chloroform. This was a great improvement; hut accuracy was not secured, because the proportion of chloroform given up varies with the temperature of the room, with the slowness or rapidity of the patient’s breathing, and with the cooling of the chloroform, which is not entirely prevented by the water-jacket. Clover has devised an appa¬ ratus, consisting of a bag hold¬ ing 8000 cubic inches of air, which is suspended from the coat collar at the back of the administrator, and connected with the face-piece by a flexi¬ ble tube (Fig. 2 ). The bag is charged by means of a bellows (Fig. 1, i) measuring 1000 cubic inches; and the air is passed through a box warmed with hot water, into which is introduced, at each filling of the bellows, as much chloro¬ form as is required for 1000 cubic inches of air. This is done with a graduated glass S 3 ’ringe (Fig. 1 , 2 ) adjusted by a screw on the piston-rod to take up no more than the quan¬ tity determined on, which is usuall}' from 30 to 40 mimims. When the bag is full enough, the tube is removed from the evaporating vessel, and the mouthpiece (Fig. 1 , 3 ) adapted to it. The patient cannot get a stronger dose than the bag is charged with; but the pro¬ portion can be made an}’ degree weaker, b}’ regulating the size of an opening in the mouthpiece, which admits additional air. The result of Clover’s experience with this instrument is of the most favorable character. He has administered this anaesthetic in more than 3000 cases without an accident of an}’ kind. The principal points to be attended to during the inhalation of this potent agent are, that it be not given too suddenly, or in too concentrated a form ; and that, whilst under its influence, the patient be not raised into the erect or sitting position. If lint be used, it may be too much saturated, and be held too closely applied to the mouth and nostrils; and the patient will not be able to get suflScient atmospheric air, and may speedily become partially asphyxiated, choking violently, struggling to get free, and becoming purple in the face, with a full slow pulse. Care should be taken not to compress the abdomen in holding the patient; for, as the respiration becomes chiefly or wholly diaphragmatic, it may Clover’s Chluroform Apparatus. Fig. 2 . Administration of Chloroform by Clover’s Apparatus. CAUTIONS REGARDING CHLOROFORM. 81 be seriously interrupted b}' any pressure on the abdominal wall. Whilst under the influence of chloroform, the patient should never be raised up, as has just been stated ; for as this agent exercises a powerful sedative action on the heart, sudden and perhaps fatal syncope may ensue from putting the patient into the erect position. Hence, also, it is dangerous to administer it in those operations that require to be performed whilst the patient is erect. It is well to caution the patient not to take any¬ thing to eat for two or three hours before its administration, lest it induce vomiting of the partiallj' digested meal. With due caution, it may be given with perfect safety to individuals of all ages. 1 have operated on infants less than a week old, as well as on octogenarians, under its influence. In administering it to young children. Snow recom¬ mends its dilution with rectified spirit. The first influence of chloroform appears to be exercised upon the nervous S 3 ’stem. The patient becomes excited and talkative, and a state of unconsciousness is induced, the muscular sj^stem at the same time being rendered rigid and tense. At this time the heart’s action is usually quickened, and more forcible than natural. As the adminis¬ tration of the chloroform continues, however, complete paralysis of sensation and motion is induced. The patient becomes altogether unconscious to all external impressions, the muscles become relaxed and the action of the heart slow and feeble. This diminution in the power of the heart’s action is well marked in the lessened force of the jet of blood from cut arteries. The respirations become shallow and feeble, in proportion as the sensibility' of the nervous sy'stem and the energy' of the muscular movements are lessened, and the blood in the arteries becomes dark; in fact, a semi-asphyxial state sets in. When thus fully anaesthetized, the patient is undoubtedly^ on the very verge of death, and requires the most careful watching by the person who administers the chloroform ; his finger should never be off the pulse, nor his eyes taken away from the countenance of the patient. The breathing should be very carefully observed: when it becomes embarrassed chloroform must be given sparingly^, and when it becomes stertorous it should be discon¬ tinued entirely. In this state, the inhalation of a small additional quantity of this potent agent, the application of the vapor in too con¬ centrated a state, or the sudden rising up of the patient, might occasion death from paraly'sis of the heart. If the inhalation of chloroform have been suspended, great care should be taken when its administration is recommenced, lest the already enfeebled heart be entirely overpowered by the influence of too large a volume of vapor suddenly given in a concentrated form. It should be borne in mind that it is not necessary in all operations to administer chloroform to the same extent. In all the greater operations, as amputations, lithotomy', and the ligature of arteries, enough should be given to completely paralyze muscular movement, as well as to sus¬ pend sensibility and consciousness. In operations for hernia, also, and all other proceedings implicating the abdominal walls, if complete mus¬ cular relaxation be not induced, great inconvenience and not a little danger may result. Sv), also, in very' painful operations about the anus and genital organs, a full dose of chloroform should be given. But for the removal of many tumors about the trunk, or in many' of the minor operations on the extremities and about the head and face, muscular relaxation is not so necessary; and it will be sufficient to give enough chloroform merely' to suspend sensibility and consciousness to pain. In certain diseased conditions of the system the administration of chlo- 32 GENERAL REMARKS ON OPERATIONS. reform requires much care; but. as a general rule, it may be stated that, whenever the constitutional disease has not advanced to such a de