SURGERY (Fr. chirurgie, from Gr. χειρουργία, i.e. handwork), the profession and art of the surgeon (chirurgien), connected specially with the cure of diseases or injuries by operative manual and instrumental treatment.
History.—Surgery in all countries is as old as human needs. A certain skill in the stanching of blood, the extraction of arrows, the binding up of wounds, the supporting of broken limbs by splints, and the like, together with an instinctive reliance on the healing power of the tissues, has been common to men everywhere. In both branches of the Indo-European stock surgical practice (as well as medical) reached a high degree of perfection at a very early period. It is a matter of controversy whether the Greeks got their medicine (or any of it) from the Hindus (through the medium of the Egyptian priesthood), or whether the Hindus owed that high degree of medical and surgical knowledge and skill which is reflected in Charaka (1st century A.D.) and Suśruta (2nd century) (commentators of uncertain date on the Yajur-Veda) to their Contact with Western civilization after the campaigns of Alexander. The evidence in favour of the former view is ably stated by Wise in the Introduction to his History of Medicine Among the Asiatics (London, 1868). The correspondence between the Suśruta and the Hippocratic Collection is closest in the sections relating to the ethics of medical practice; the description, also, of lithotomy in the former agrees almost exactly with the account of the Alexandrian practice as given by Celsus. But there are certainly some dexterous operations described in Suśruta (such as the rhinoplastic) which were of native invention; the elaborate and lofty ethical code appears to be of pure Brahmanical origin; and the copious materia medica (which included arsenic, mercury, zinc, and many other substances of permanent value) does not contain a single article of foreign source. There is evidence also (in Arrian, Strabo and other writers) that the East enjoyed a proverbial reputation for medical and surgical wisdom at the time of Alexander's invasion. We may give the first place, then, to the Eastern branch of the Indo-European stock in a sketch of the rise of surgery, leaving as insoluble the question of the date of the Sanskrit compendiums or compilations which pass under the names of two representative persons, Charaka and Suśruta (the dates assigned to these ranging as widely as 500 years on each side of the Christian era).
The Suśruta speaks throughout of a single class of practitioners who undertook both surgical and medical cases. Nor were Hindu. there any fixed degrees or orders of skill within the profession; even lithotomy, which at Alexandria was assigned to specialists, was to be undertaken by any one, the leave of the raja having been first obtained. The only distinction recognized between medicine and surgery was in the inferior order of barbers, nail-trimmers, ear-borers, tooth-drawers and phlebotomists, who were outside the Brahmanical caste.
Suśruta describes more than one hundred surgical instruments, made of steel. They should have good handles and firm joints, be well polished, and sharp enough to divide a hair; they should be perfectly clean, and kept in flannel in a wooden box. They included various shapes of scalpels, bistouries, lancets, scarifiers, saws, bone-nippers, scissors, trocars and needles. There were also blunt hooks, loops, probes (including a caustic-holder), directors, sounds, scoops and forceps (for polypi, &c.), as well as catheters, syringes, a rectal speculum and bougies. There were fourteen varieties of bandage. The favourite form of splint was made of thin slips of bamboo bound together with string and cut to the length required. Wise says that he had frequently used “this admirable splint,” particularly for fractures of the thigh, humerus, radius and ulna, and it was subsequently adopted in the English army under the name of the “patent rattan-cane splint.”
Fractures were diagnosed, among other signs, by crepitus. Dislocations were elaborately classified, and the differential diagnosis given; the treatment was by traction and counter traction, circumduction and other dexterous manipulation. Wounds were divided into incised, punctured, lacerated, contused, &c. Cuts of the head and face were sewed. Skill in extracting foreign bodies was carried to a great height, the magnet being used for iron particles under certain specified circumstances. Inflammations were treated by the usual antiphlogistic regimen and appliances; venesection was practised at several other points besides the bend of the elbow; leeches were more often resorted to than the lancet; cupping also was in general use. Poulticing, fomenting and the like were done as at present. Amputation was done now and then, notwithstanding the want of a good control over the hemorrhage; boiling oil was applied to the stump, with pressure by means of a cup-formed bandage, pitch being sometimes added. Tumours and enlarged lymphatic glands were cut out, and an arsenical salve applied to the raw surfaces to prevent recurrence. Abdominal dropsy and hydrocele were treated by tapping with a trocar; and varieties of hernia were understood, omental hernia being removed by operation on the scrotum. Aneurisms were known, but not treated; the use of the ligature on the continuity of an artery, as well as on the cut end of it in a flap, is the one thing that a modern surgeon will miss somewhat noticeably in the ancient surgery of the Hindus; and the reason of their backwardness in that matter was doubtless their want of familiarity with the course of the arteries and with the arterial circulation. Besides the operation already mentioned, the abdomen was opened by a short incision below the umbilicus slightly to the left of the middle line for the purpose of removing intestinal concretions or other obstruction (laparotomy). Only a small segment of the bowel was exposed at one time; the concretion when found was removed, the intestine stitched together again, anointed with ghee and honey, and returned into the cavity. Lithotomy was practised, without the staff. There was a plastic operation for the restoration of the nose, the skin being taken from the cheek adjoining, and the vascularity kept up by a bridge of tissue. The ophthalmic surgery included extraction of cataract. Obstetric operations were various, including cesarean section and crushing the foetus.
The medication and constitutional treatment in surgical cases were in keeping with the general care and elaborateness of their practice, and with the copiousness of their materia medica. Ointments and other external applications had usually a basis of ghee (or clarified butter), and contained, among other things, such metals as arsenic, zinc, copper, mercury and sulphate of iron. For every emergency and every known form of disease there were elaborate and minute directions in the śâstras, which were taught by the physician-priests to the young aspirants. Book learning was considered of no use without experience and manual skill in operations; the different surgical operations were shown to the student upon wax spread on a board, on gourds, cucumbers and other soft fruits; tapping and puncturing were practised on a leathern bag filled with water or soft mud; scarifications and bleeding on the fresh hides of animals from which the hair had been removed; puncturing and lancing upon the hollow stalks of water-lilies or the vessels of dead animals; bandaging was practised on flexible models of the human body; sutures on leather and cloth; the plastic operations on dead animals; and the application of caustics and cauteries on living animals. A knowledge of anatomy was held to be necessary, but it does not appear that it was systematically acquired by dissection. Superstitions and theurgic ideas were diligently kept up so as to impress the vulgar. The whole body of teaching, itself the slow growth of much close observation and profound thinking during the vigorous period of Indo-Aryan progress, was given out in later times as a revelation from heaven, and as resting upon an absolute authority. Pathological principles were not wanting, but they were derived from a purely arbitrary or conventional physiology (wind, bile and phlegm); and the whole elaborate fabric of rules and directions, great though its utility must have been for many generations, was without the quickening power of reason and freedom, and became inevitably stiff and decrepit.
The Chinese appear to have been far behind the Hindus in their knowledge of medicine and surgery, notwithstanding Chinese. that China profited at the same time as Tibet by the missionary propagation of Buddhism. Surgery in particular had hardly developed among them beyond the merest rudiments, owing to their religious respect for dead bodies and their unwillingness to draw blood or otherwise interfere with the living structure. Their anatomy and physiology have been from the earliest times unusually fanciful, and their surgical practice has consisted almost entirely of external applications. Tumours and boils were treated by scarifications or incisions, The distinctive Chinese surgical invention is acupuncture, or the insertion of fine needles, of hardened silver or gold, for an inch or more (with a twisting motion) into the seats of pain or inflammation. Wise says that “the needle is allowed to remain in that part several minutes, or in some cases of neuralgia for days, with great advantage”; rheurnatism and chronic gout were among the localized pains so treated. There are 367 points specified where needles may be inserted without injuring great vessels and vital organs.
Cupping-vessels made of cow-horn have been found in ancient Egyptian tombs. On monuments and the walls of temples Egyptian. are figures of patients bandaged, or undergoing operation at the hands of surgeons. In museum collections of Egyptian antiquities there are lancets, forceps, knives, probes, scissors, &c. Ebers interprets a passage in the papyrus discovered by him as relating to the operation of cataract. Surgical instruments for the ear are figured, and artificial teeth have been found in mummies. Mummies have also been found with well-set fractures. Herodotus describes Egypt, notwithstanding its fine climate, as being full of medical practitioners, who were all “specialists.” The ophthalmic surgeons were celebrated, and practised at the court of Cyrus.
Greek Surgery.—As in the case of the Sanskrit medical writings, the earliest Greek compendiums on surgery bear witness Greek. to a long organic growth of knowledge and skill through many generations. In the Homeric picture of society the surgery is that of the battlefield, and it is of the most meagre kind. Achilles is concerned about the restoration to health of Machaon for the reason that his skill in cutting out darts and applying salves to wounds was not the least valuable service that a hero could render to the Greek host. Machaon probably represents an amateur, whose taste had led him, as it did Melampus, to converse with centaurs and to glean some of their traditional wisdom. Between that primitive state of civilization and the date of the first Greek treatises there had been along interval of gradual progress.
The surgery of the Hippocratic Collection (age of Pericles) bears every evidence of finish and elaboration. The two treatises on Hippocratic Surgery. fractures and on dislocations respectively are hardly surpassed in some ways by the writings of the present mechanical age. Of the four dislocations of the shoulder the displacement downwards into the axilla is given as the only one at all common. The two most usual dislocations of the femur were backwards on to the dorsum ilii and forwards on to the obturator region. Fractures of the spinous processes of the vertebrae are described, and caution advised against trusting those who would magnify that injury into fracture of the spine itself. Tubercles (φύματα) are given as one of the causes of spinal curvature, an anticipation of Pott's diagnosis. In all matters of treatment there was the same fertility of resource as in the Hindu practice; the most noteworthy point is that shortening was by many regarded as inevitable after simple fracture of the femur. Fractures and dislocations were the most complete chapters of the Hippocratic surgery; the whole doctrine and practical art of them had arisen (like sculpture) with no help from dissection, and obviously owed its excellence to the opportunities of the palaestra. The next most elaborate chapter is that on wounds and injuries of the head, which refers them to a minute subdivision, and includes the depressed fracture and the contrecoup. Trephining was the measure most commonly resorted to, even where there was no compression. Numerous forms of wounds and injuries of other parts are specified. Ruptures, piles, rectal polypi, fistula in ano and prolapses ani were among the other conditions treated. The amputation or excision of tumours does not appear to have been undertaken so freely as in Hindu surgical practice; nor was lithotomy performed except by a specially expert person now and then. The diagnosis of empyema was known, and the treatment of it was by an incision in the intercostal space and evacuation of the pus. Among their instruments were forceps, probes, directors, syringes, rectal speculum, catheter and various kinds of cautery.
Between the Hippocratic era and the founding of the school of Alexandria (about 300 B.C.) there is nothing of surgical Alexandrian Period. progress to dwell upon. The Alexandrian epoch stands out prominently by reason of the enthusiastic cultivation of human anatomy—there are allegations also of vivisection—at the hands of Herophilus (335-280 B.C.) and Erasistratus (280 B.C.). The substance of this movement appears to have been precision of diagnosis (not unattended with pedantic minuteness), boldness of operative procedure, subdivision of practice into a number of specialities, but hardly a single addition to the stock of physiological or pathological ideas, or even to the traditional wisdom of the Hippocratic time. “The surgeons of the Alexandrian school were all distinguished by the nicety and complexity of their dressings and bandagings, of which they invented a great variety.” Herophilus boldly used the knife even on internal organs such as the liver and spleen, which latter he regarded “as of little consequence in the animal economy.” He treated retention of urine by a particular kind of catheter, which long bore his name. Lithotomy was much practised by a few specialists, and one of them (Ammonius Lithotomos, 287 B.C.) is said to have used an instrument for breaking the stone in the bladder into several pieces when it was too large to remove whole. A sinister story of the time is that concerning Antiochus, son of Alexander, king of Syria (150 B.C.), who was done to death by the lithotomists when he was ten years old, under the pretence that he had stone in the bladder, the instigator of the crime being his guardian and supplanter Diodotus.
The treatise of Celsus, De re medica (reign of Augustus), reflects the state of surgery in the ancient world for a period of several centuries: it is the best record of the Alexandrian practice itself, and it may be taken to stand for the Roman practice of the period following. Great jealousy of Greek medicine and surgery was expressed by many of the Romans of the republic, notably by Cato the Elder (234-149 B.C.), who himself practised on his estate according to the native traditions. His medical observations are given in De re rustica. In reducing dislocations he made use of the following incantation: “Huat hanat ista pista sista damiato damnaustra.” The first Greek surgeon who established himself in Rome is said to have been Archagathus, whose fondness for the knife and cautery at length led to his expulsion by the populace. It was in the person of Asclepiades, the contemporary and friend of Cicero, that the Hellenic medical practice acquired a permanent footing in Rome. He confined his practice mostly to medicine, but he is credited with practising the operation of tracheotomy. He is one of those whom Tertullian quotes as practising vivisect ions for the gratification of their curiosity (De anima, 15). The next figure in the surgical history is Celsus, who devotes the 7th and 8th books of his De re Celsus. medica exclusively to surgery. There is not much in these beyond the precepts of the Brahmanical śâstras and the maxims and rules of Greek surgery. Plastic operations for the restoration of the nose, lips and ears are described at some length, as well as the treatment of hernia by taxis and operation; in the latter it was recommended to apply the actual cautery to the canal after the hernia had been returned. The celebrated description of lithotomy is that of the operation as practised long before in India and at Alexandria. The treatment of sinuses in various regions is dwelt upon, and in the case of sinuses of the thoracic wall resection of the rib is mentioned. Trephining has the same prominent place assigned to it as in the Greek surgery. The resources of contemporary surgery may be estimated by the fact that subcutaneous urethrotomy was practised when the urethra was blocked by a calculus. Amputation of an extremity is described in detail for the first time in surgical literature. Mention is made of a variety of ophthalmic operations, which were done by specialists after the Alexandrian fashion.
Galen's practice of surgery was mostly in the early part of his career (b. A.D. 130), and there is little of special surgical Galen. interest in his writings, great as their importance is for anatomy, physiology and the general doctrines of disease. Among the operations credited to him are resection of aportion of the sternum for caries and ligature of the temporal artery. It may be assumed that surgical practice was in a flourishing condition all through the period of the empire from the accounts preserved by Oribasius of the great surgeons Antyllus, Leonides, Rufus and Heliodorus. Antyllus (A.D. 300) Roman Empire. is claimed by Häser as one of the greatest of the world's surgeons; he had an operation for aneurism (tying the artery above and below the sac, and evacuating its contents), for cataract, for the cure of stammering; and he treated contractures by something like tenotomy. Rufus and Heliodorus are said to have practised torsion for the arrest of haemorrhage; but in later periods both that and the ligature appear to have given way to the actual cautery. Häser speaks of the operation for scrotal hernia attributed to Heliodorus as “a brilliant example of the surgical skill during the empire.” The same surgeon treated stricture of the urethra by internal section. Both Leonides and Antyllus removed glandular swellings of the neck (strumae); the latter ligatured vessels before cutting them, and gives directions for avoiding the carotid artery and jugular vein. Flap-amputations were practised by Leonides and Heliodorus. But perhaps the most striking illustration of the advanced surgery of the period is the freedom with which bones were resected, including the long bones, the lower jaw and the upper jaw.
Whatever progress or decadence surgery may have experienced during the next three centuries is summed up in the authoritative Byzantine. treatise of Paulus of Aegina (A.D. 650). Of his seven books the sixth is entirely devoted to operative surgery, and the fourth is largely occupied with surgical diseases. The importance of Paulus for surgical history during several centuries on each side of his own period will appear from the following remarks of Francis Adams (1796-1861) in his translation and commentary (ii. 247):—
“This book (bk. vi.) contains the most complete system of operative surgery which has come down to us from ancient times. . . . Haly Abbas (d. A.D. 994) in the 9th book of his Practica copies almost everything from Paulus. Albucasis [Abulcasis] (10th century A.D.) gives more original matter on surgery than any other Arabian author, and yet, as will be seen from our commentary, he is indebted for whole chapters to Paulus. In the Continens of Rhases, that precious repository of ancient opinions on medical subjects, if there be any surgical information not to be found in our author it is mostly derived from Antyllus and Archigenes. As to the other authorities, although we will occasionally have to explain their opinions upon particular subjects, no one has treated of surgery in a systematical manner; for even Avicenna, who treats so fully of everything else connected with medicine, is defective in his accounts of surgical operations; and the descriptions which he does give of them are almost all borrowed from our author. The accounts of fractures and dislocations given by Hippocrates and his commentator Galen may be pronounced almost complete; but the information which they supply upon most other surgical subjects is scanty.”
Paulus' sixth book, with the valuable commentary of Adams, brings the whole surgery of the ancient world to a focus. Paulus is credited with the principle of local depletion as against general, with the lateral operation for stone instead of the mesial and with understanding the merits of a free external incision and a limited internal, with the diagnosis of aneurism by anastomosis, with an operation for aneurism like that of Antyllus, with amputation of the cancerous breast by crucial incision, and with the treatment of fractured patella.
The Arabians have hardly any greater merit in medicine than that of preserving intact the bequest of the ancient world. Arabian. To surgery in particular their services are small—first, because their religion proscribed the practice of anatomy, and, secondly, because it was a characteristic of their race to accept with equanimity the sufferings that fell to them, and to decline the means of alleviation. The great names of the Arabian school, Avicenna (980-1037) and Averroes (1126-1198), are altogether unimportant for surgery. Their one distinctively surgical writer was Abulcasim (d. 1122), who is chiefly celebrated for his free use of the actual cautery and of caustics. He showed a good deal of character in declining to operate on goitre, in resorting to tracheotomy but sparingly, in refusing to meddle with cancer, and in evacuating large abscesses by degrees.
For the five hundred years following the work of Paulus of Aegina there is nothing to record but the names of a few Medieval. practitioners at the court and of imitators or compilers. Meanwhile in western Europe (apart from the Saracen civilisation) a medical school had grown up at Salerno, which in the 10th century had already become famous. From it issued the Regimen salernitanum, a work used by the laity for several centuries, and the Compendium salernitanum, which circulated among the profession. The decline of the school dates from the founding of a university at Naples in 1224. In its best period princes and nobles resorted to it for treatment from all parts of Europe. The hôtel dieu of Lyons had been founded in 560, and that of Paris a century later. The school of Montpellier was founded in 1025, and became the rallying point of Arabian and Jewish learning. A good deal of the medical and surgical practice was in the hands of the religious orders, particularly of the Benedictines. The practice of surgery by the clergy was at length forbidden by the Council of Tours (1163). The surgical writings of the time were mere reproductions of the classical or Arabian authors. One of the first to go back to independent observation and reflection was William of Saliceto, who belonged to the school of Bologna; his work (1275) advocates the use of the knife in many places where the actual cautery was used by ancient prescription. A greater name in the history of medieval surgery is that of his pupil Lanfranchi of Milan, who migrated (owing to political troubles) first to Lyons and then to Paris. He distinguished between arterial and venous hemorrhage, and is said to have used the ligature for the former. Contemporary with him in France was Henri de Mondeville (Hermondaville) of the school of Montpellier, whose teaching is best known through that of his more famous pupil Guy de Chauliac; the Chirurgie of the latter bears the date of 1363, and marks the advance in precision which the revival of anatomy by Mondino had made possible. Eighteen years before Lanfranchi came to Paris a college of surgeons was founded there (1279) by Pitard, who had accompanied St Louis to Palestine as his surgeon. The college was under the protection of St Cosmas and St Damianus, two practitioners of medicine who suffered martyrdom in the reign of Diocletian, and it became known as the Collège de St Côme. From the time that Lanfranchi joined it it attracted many pupils. It maintained its independent existence for several centuries, alongside the medical faculty of the university; the corporations of surgeons in other capitals, such as those of London and Edinburgh, were modelled upon it.
The 14th and 15th centuries are almost entirely without interest for surgical history. The dead level of tradition is broken first by two men of originality and genius—P. Paracelsus (1493-1541) and Paré, and by the revival of anatomy at the hands of Andreas Vesalius (1514-1564) and Gabriel Fallopius (1523-1562), professors at Padua. Apart from the mystical form in which much of his teaching was cast, Paracelsus has Paracelsus. great merits as a reformer of surgical practice. “The high value of his surgical writings,” says Häser, “has been recognized at all times, even by his opponents.” It is not, however, as an innovator in operative surgery, but rather as a direct observer of natural processes, that Paracelsus is distinguished. His description of “hospital gangrene,” for example, is perfectly true to nature; his numerous observations on syphilis are also sound and sensible; and he was the first to point out the connexion between cretinism of the offspring and goitre of the parents. He gives most prominence to the healing of wounds. His special surgical treatises are Die kleine Chirurgie (1528) and Die grosse Wund-Arznei (1536-1537)—the latter being the best known of his works. Somewhat later in date, and of much greater concrete importance for surgery Paré. than Paracelsus, is Ambroise Paré (1510-1590). He began life as apprentice to a barber-surgeon in Paris and as a pupil at the hôtel dieu. His earliest opportunities were in military surgery during the campaign of Francis I. in Piedmont. Instead of treating gunshot wounds with hot oil, according to the practice of the day, he had the temerity to trust to a simple bandage; and from that beginning he proceeded to many other developments of rational surgery. In 1545 he published at Paris La Méthode de traicter les playes faictes par hacquebutes et aultres bastons à feu. The same year he began to attend the lectures of Sylvius, the Paris teacher of anatomy, to whom he became prosector; and his next book was an Anatomy (1550). His most memorable service was to get the use of the ligature for large arteries generally adopted, a method of controlling the hemorrhage which made amputation on a large scale possible for the first time. Like Paracelsus, he writes in the language of the people, while he is free from the encumbrance of mystical theories, which detract from the merits of his fellow reformer in Germany. It is only in his book on monsters, written towards the end of his career, that he shows himself to have been by no means free from superstition. Paré was adored by the army and greatly esteemed by successive French kings; but his innovations were opposed, as usual, by the faculty, and he had to justify the use of the ligature as well as he could by quotations from Galen and other ancients.
Surgery in the 16th century recovered much of the dexterity and resource that had distinguished it in the best periods of 16th Century. antiquity, while it underwent the developments opened up to it by new forms of wounds inflicted by new weapons of warfare. The use of the staff and other instruments of the “apparatus major” was the chief improvement in lithotomy. A “radical cure” of hernia by sutures superseded the old application of the actual cautery. The earlier modes of treating stricture of the urethra were tried; plastic operations were once more done with something like the skill of Brahmanical and classical times; and ophthalmic surgery was to some extent rescued from the hands of ignorant pretenders. It is noteworthy that even in the legitimate profession dexterous special operations were kept secret; thus the use of the “apparatus major” in lithotomy was handed down as a secret in the family of Laurence Colot, a contemporary of Paré's.
The 17th century was distinguished rather for the rapid progress of anatomy and physiology, for the Baconian and 17th Century. Cartesian philosophies, and the keen interest taken in complete systems of medicine, than for a high standard of surgical practice. The teaching of Paré that gunshot wounds were merely contused and not poisoned, and that simple treatment was the best for them, was enforced anew by Magati (1579-1647), Wiseman and others. Trephining was freely resorted to, even for inveterate migraine; Philip William, prince of Orange, is said to have been trephined seventeen times. Flap-amputations, which had been practised in the best period of Roman surgery by Leonides and Heliodorus, were reintroduced by Lowdham, an Oxford surgeon, in 1679, and probably used by Wiseman, who was the first to practise the primary major amputations. Fabriz von Hilden (1560-1634) introduced a form of tourniquet, made by placing a piece of wood under the bandage encircling the limb; out of that there grew the block-tourniquet of Morel, first used at the siege of Besançon in 1674; and this, again, was superseded by Jean Louis Petit's (1674-1750) screw-tourniquet in 1718. Strangulated hernia, which was for long avoided, became a subject of operation. Lithotomy by the lateral method came to great perfection in the hands of Jacques Beaulieu. To this century also belong the first indications (not to mention the Alexandrian practice of Ammonius) of crushing the stone in the bladder. The theory and practice of transfusion of blood occupied much attention, especially among the busy spirits of the Royal Society, such as Boyle, Lower and others. The seat of cataract in the substance of the lens was first made out by two French surgeons, Quarré and Lasnier. Perhaps the most important figure in Wiseman. the surgical history of the century is Richard Wiseman (1622?-1676) the father of English surgery. Wiseman took the Royalist side in the wars of the Commonwealth, and was surgeon to James I. and Charles I., and accompanied Charles II. in his exile in France and the Low Countries. After serving for a time in the Spanish fleet, he joined the Royalist cause in England and was taken prisoner at the battle of Worcester. At the Restoration he became serjeant-surgeon to Charles II., and held the same office under James II. His Seven Chirurgical Treatises were first published in 1676, and went through several editions; they relate to tumours, ulcers, diseases of the anus, king's evil (scrofula), wounds, fractures, luxations and lues venerea. Wiseman was the first to advocate primary amputation (or operation before the onset of fever) in cases of gunshot wounds and other injuries of the limbs. He introduced also the practice of treating aneurysms by compression, gave an accurate account of fungus articulorum, and improved the operative procedure for hernia.
The 18th century marks the establishment of surgery on a broader basis than the skill of individual surgeons of the court and army, and on a more scientific basis than the rule of thumb of the multitude of barber-surgeons and other inferior orders of practitioners. In Paris the Collège de St Côme gave way to the Academy of Surgery in 1731, with Petit as director, 18th Century. to which was added at a later date the École Pratique de Chirurgie, with François Chopart (1743-1795) and Pierre Desault (1744-1795) among its first professors. The Academy of Surgery set up a very high standard from the first, and exercised great exclusiveness in its publications and its honorary membership. In London and Edinburgh the development of surgery proceeded on less academical lines, and with greater scope for individual effort. Private dissecting rooms and anatomical theatres were started, of which perhaps the most notable was Dr William Hunter's (1718-1783) school in Great Windmill Street, London, inasmuch as it was the first perch of his more famous brother John Hunter (1728-1793). In Edinburgh, Alexander Monro (1697-1767), first of the name, became professor of anatomy to the company of surgeons in 1719, transferring his title and services to the university the year after; as he was the first systematic teacher of medicine or surgery in Edinburgh, he is regarded as the founder of the famous medical school of that city. In both London and Edinburgh a company of barbers and surgeons had been in existence for many years before; but it was not until the association of these companies with the study of anatomy, comparative anatomy, physiology and pathology that the surgical profession began to take rank with the older order of physicians. Hence the significance of the eulogy of a living surgeon on John Hunter: “More than any other man he helped to make us gentlemen” (Hunterian Oration, 1877). The state of surgery in Germany may be inferred from the fact that the teaching of it at the new university of Göttingen was for long in the hands of Albrecht von Haller (1708-1777), whose office was “professor of theoretical medicine.” In the Prussian army it fell to the regimental surgeon to shave the officers. At Berlin a medico-chirurgical college was founded by Surgeon-General Ernst von Holtzendorff (1688-1751) in 1714, to which was joined in 1726 a school of clinical surgery at the Charité. Military surgery was the original purpose of the school, which still exists, side by side with the surgical cliniques of the faculty, as the Friedrich Wilhelm's Institut. In Vienna, in like manner, a school for the training of army surgeons was founded in 1785—Joseph's Academy or the Josephinum. The first systematic teaching of surgery in the United States was by Dr Shippen at Philadelphia, where the medical college towards the end of the century was largely officered by pupils of the Edinburgh school. A great part of the advance during the 18th century was in surgical pathology, including Petit's observations on the formation of thrombi in severed vessels, Hunter's account of the reparative process, Benjamin Bell's classification of ulcers, the observations of Duhamel and others on the formation of callus and on bone-repair in general, Pott's distinction between spinal curvature from caries or abscess of the vertebrae and kyphosis from other causes, observations by various surgeons on chronic disease of the hip, knee, and other joints, and Cheselden's description of neuroma. Among the great improvements in surgical procedure we have Cheselden's operation of lithotomy (six deaths in eighty cases), Sir Caesar Hawkins's (1711-1786) cutting gorget for the same (1753), Hunter's operation (1785) for popliteal aneurism by tying the femoral artery in the canal of the triceps where its walls were sound (“excited the greatest wonder,” Assalini), Petit's, Desault's and Percival Pott's (1714-1788) treatment of fractures, Gimbernat's (Barcelona) operation for strangulated femoral hernia, Pott's bistoury for fistula, Charles White's (1728-1813, Manchester) and Henry Park's (1745-1831, Liverpool) excision of joints, Petit's invention of the screw-tourniquet, the same surgeon's operation for lacrymal fistula, Chopart's partial amputation of the foot, Desault's bandage for fractured clavicle, William Bromfield's (1712-1792) artery hook, and William Cheselden's (1688-1752) operation of iridectomy. Other surgeons of great versatility and general merit were Sharp of London, Benjamin Gooch (fl. 1775) of Norwich, William Hey (1736-1819) of Leeds, David and Claude Nicolas Le Cat (1705-1768) of Rouen, Raphaël Sabatier (1732-1811), Georges de La Faye (1701-1781), Ledran, Antoine Louis (1723-1792), Sauveur Morand (1697-1773) and Pierre Percy (1754-1825) of Paris, Bertrandi of Turin, Troja of Naples, Palleta of Milan, Schmucker of the Prussian army, August Richter of Göttingen, Siebold of Würzburg, Olaf Acrel of Stockholm and Callisen of Copenhagen.
Two things gave surgical knowledge and skill in the 19th century a character of scientific or positive 19th Century. cumulativeness and a wide diffusion through all ranks of the profession.[1] The one was the founding of museums of anatomy and surgical pathology by the Hunters, Guillaume Dupuytren (1777-1835), Jules Cloquet (1790-1843), J. F. Blumenbach (1752-1840), John Barclay (1758-1826), and a great number of more modern anatomists and surgeons; the other was the method of clinical teaching, exemplined in its highest form of constant reference to principles by Thomas Lawrence (1711-1783) and James Syme (1799-1870). In surgical procedure the discovery of the anaesthetic properties of ether, chloroform, methylene, &c., was of incalculable service; while the conservative principle in operations upon diseased or injured parts, and especially what may be called the hygienic idea (or, more narrowly, the antiseptic and aseptic principles) in the conditions governing surgery, were strikingly beneficial.
The following were among the more important additions to the resources of the surgical art: the thin thread ligature for arteries, introduced by Jones of Jersey (1805); the revival of torsion of arteries by Jean Amussat (1796-1856) [1829]; the practice of drainage by Pierre Marie Chassaignac (1805-1879) [1859]; aspiration by Philippe Pelletan (1747-1829) and recent improvers; the plaster-of-Paris bandage or other immovable application for simple fractures, clubfoot, &c. (an old Eastern practice recommended in Europe about 1814 by the English consul at Basra); the re-breaking of badly set fractures; galvano-caustics and écraseurs; the general introduction of resection of joints (Sir William Fergusson (1808-1877), Syme and others); tenotomy by Jacques Delpech (1777-1832) and Louis Stromeyer (1804-1876) [1831]; operation for squint by Johann Dieffenbach (1795-1847) [1842]; successful ligature of the external iliac for aneurism of the femoral by John Abernethy (1764-1831) [1806], ligature of the subclavian in the third portion by Astley Cooper (1768-1841) [1806], and in its first portion by Colles; crushing of stone in the bladder by Gruithuisen of Munich (1819) and Jean Civiale (1792-1867) of Paris [1826]; cure of ovarian dropsy by removing the cyst (since greatly perfected); discovery of the ophthalmoscope, and many improvements in ophthalmic surgery by Alfred von Gräfe (1830-1899) and others; application of the laryngoscope in operations on the larynx by Jean Czermak (1828-1873) [1860] and others; together with additions to the resources of aural surgery and dentistry. The great names in the surgery of the first half of the century besides those mentioned are: Antonio Scarpa of Italy (1747-1832); Alexis Boyer (1757-1833), Félix Larrey (1766-1842)—to whom Napoleon left a legacy of a hundred thousand francs, with the eulogy: “C'est l'homme le plus vertueux que j'aie connu,” Philibert Roux (1780-1854), Jacques Lisfranc (1790-1847), Alfred Louis Velpeau (1795-1868), Joseph Malgaigne (1806-1865), Auguste Nélaton (1807-1873)—all of the French school; of the British school, John Bell (1763-1820), Charles Bell (1774-1842), Allan Burns (1781-1813), Robert Liston (1794-1847), James Wardrop (1782-1869), Astley Cooper, Henry Cline (1750-1827), Benjamin Travers (1783-1858), Benjamin Brodie (1783-1862), Edward Stanley (1793-1862) and George Guthrie (1785-1856); in the United States, V. Mott, S. D. Gross and others; in Germany, Kern and Schuh of Vienna, Von Walther and Textor of Würzburg, Chelius, Hesselbach and the two Langenbecks-Konrad (1776-1851) and Bernhard (1810-1887).
Authorities.—Wise, History of Medicine among the Asiatics (2 vols., London, 1868); Paulus Aegineta, translated with commentary on the knowledge of the Greeks, Romans and Arabians in medicine and surgery, by Francis Adams (3 vols., London, 1844-1847); Häser, Gesch. d. Medicin (3rd ed., 1875-1881), vols. i. and ii. (C. C.)
Modern Practice of Surgery.[2]—A great change has taken place in the practice of surgery since the middle of the 19th century, in consequence of the new science of bacteriology, and the introduction of aseptic methods, due to the teaching of Lord Lister.
It had long been known that subcutaneous injuries followed a far more satisfactory course than those with wounds, and the history of surgery gives evidence that surgeons endeavoured, by the use of various dressings, empirically to prevent the evils which were matters of common observation during the healing of open wounds. Various means were also adopted to prevent the entrance of air, as, for instance, in the opening of abscesses by the “valvular method” of Abernethy, and by the subcutaneous division of tendons in “club-foot.” Balsams and turpentine and various forms of spirit were the basis of many varieties of dressing. These different dressings were frequently cumbersome and difficult of application, and they did not attain the object aimed at, while, at the same time, they shut in the discharges and gave rise to other evils which prevented rapid and painless healing. In the beginning of the 19th century these complicated dressings began to lose favour, and operating surgeons went to the opposite extreme and applied a simple dressing, the main object of which was to allow a free escape of discharge. Others applied no dressing at all, laying the stump of a limb after amputation on a piece of dry lint, avoiding thereby any unnecessary movement of the parts. Others, again, left the wound open for some hours after an operation, preventing in this way any accumulation, and brought its edges and surfaces together after all oozing of blood had ceased, and after the effusion, the result of injury to the tissues in the operation had to a great extent subsided. As a result of these measures many wounds healed kindly. But in other cases inflammation occurred, accompanied by pain and swelling, and the formation of pus. High fever also, due to the unhealthy state of the wound, was observed. These conditions often proved fatal, and surgeons attributed them to the constitution of the patient, or else thought that some poison had entered the wound, and, passing from it into the veins, had contaminated the blood and poisoned the patient. The close association between the formation of pus in wounds and the fatal “intoxication” of many of those cases encouraged the belief that the pus cells from the wound entered the circulation. Hence came the word “pyaemia.” It was also observed that a septic condition of the wound was usually associated with constitutional fever, and it was supposed that the septic matter passed into the blood—whence the term “septicaemia.” It was further observed that the crowding together of patients with open wounds increased the liability to these constitutional disasters, so every endeavour was made to separate the patients and to improve ventilation. In building hospitals the pavilion and other systems, with windows on both sides, with cross-ventilation in the wards, were adopted in order to give the utmost amount of fresh air. Hospital buildings were spread over as large an area as possible, and were restricted in height, if practicable, to two storeys. The term “hospitalism” was coined by Sir J. Y. Simpson, who collected statistics comparing hospital and private practice, by which he endeavoured to show that private patients were far less liable to such catastrophes than were those who were treated in hospitals.
This was the condition of affairs when Lister in 1860, from a study of the experimental researches of Pasteur into the Antiseptic Surgery. causes of putrefaction, stated that the evils observed in open wounds were due to the admission into them of organisms which exist in the air, in water, on instruments, on sponges, and on the hands of the surgeon or the skin of the patient. Having accepted the germ theory of putrefaction, Lister applied himself to discover the best way of preventing all harmful organisms from reaching the wound from the moment that it was made until it was healed. In the germ he had to deal with a microscopic plant, and he desired to render its growth impossible. This, he thought, could be done either by destroying the plant itself before it had the chance of entering the wound or after it had entered, or by facilitating the removal of the discharges and preventing their accumulation in the wound, and by doing everything to prevent the lowering of the vitality of the wounded tissues, because unhealthy tissues are the most liable to attack. Several substances were then known as possessing properties antagonistic to sepsis or putrefaction, and hence called “antiseptic.” Acting on a suggestion of Lemaire, Lister chose for his experiments carbolic acid, which he used at first in a crude form. He had many difficulties to contend with—the impurity of the substance, its irritating properties and the difficulty of finding the exact strength in which to use it: he feared to use it too strong, lest it should impair the vitality of the tissues and thus prevent healing; and he feared to use it too weak, lest its antiseptic qualities should be insufficient for the object in view. As dressings for wounds he used various chemical substances, which, being mixed with carbolic acid, were intended to give off a certain quantity of carbolic acid in the form of vapour, so that the wound might be constantly surrounded by an antiseptic which would destroy any organisms approaching it, and, at the same time, not interfere with its healing. At first, although he prevented pyaemia in a marked degree, he, to a certain extent, irritated the wounds and prevented rapid healing. He began his historic experiments in Glasgow and continued them on his removal to the chair of clinical surgery in Edinburgh. After many disappointments, he gradually perfected his method of performing operations and dressing wounds, which was somewhat as follows.
A patient was suffering, for instance, from disease of the foot necessitating amputation at the ankle joint. The part to be operated on was enveloped in a towel soaked with a 5% solution of carbolic acid. The towel was applied two hours before the operation, with the object of destroying the putrefactive organisms present in the skin. The patient was placed on the operating table, and brought under the influence of chloroform; the limb was then elevated to empty it of blood, and a tourniquet was applied round the limb below the knee. The instruments to be used during the operation had been previously purified by lying for half an hour in a flat porcelain dish containing carbolic acid (1 in 20). The sponges lay in a similar carbolic lotion. Towels soaked in the same solution were laid over the table and blankets near the part to be operated upon. The hands cf the operator, as well as those of his assistants, were thoroughly cleansed by washing them in carbolic lotion, free use being made of a nail brush for this purpose. The operation was performed under a cloud of carbolized watery vapour (1 in 30) from a steam spray-producer. The visible bleeding points were first ligated; the tourniquet was removed; and any vessels that had escaped notice were secured. The wound was stitched, a drainage-tube made of red rubber being introduced at one corner to prevent accumulation of discharge; a strip of “protective”—oiled silk coated with carbolized dextrin—was washed in carbolic lotion and applied over the wound. A double ply of carbolic gauze was soaked in the lotion laid over the protective, overlapping it freely. A dressing consisting of eight layers of dry gauze was placed over all, covering the stump and passing up the leg for about six inches. Over that a piece of thin mackintosh cloth was placed, and the whole arrangement was fixed with a gauze bandage. The mackintosh cloth prevented the carbolic acid from escaping and at the same time caused the discharge from the wound to spread through the gauze. The wound itself was shielded by the protective from the vapour given off by the carbolic gauze, whilst the surrounding parts, being constantly exposed to its activity, were protected from the intrusion of septic contamination. And these conditions were maintained until sound healing took place. Whenever the discharge reached the edge of the mackintosh the case required to be dressed, and a new supply of gauze was applied round the stump. Whenever the wound was exposed for dressing the stump was enveloped in the vapour of carbolic acid by means of the steam spray-producer. At first a syringe was used to keep the surface constantly wet with lotion and then a hand-spray. These dressings were repeated at intervals until the wound was healed. The drainage-tube was gradually shortened, and was ultimately removed altogether.
The object Lister had in view from the beginning of his experiments was to place the open wound in a condition as regards the entrance of organisms as nearly as possible like a truly subcutaneous wound, such as a contusion or a simple fracture, in which the unbroken skin acted as a protection to the wounded tissues beneath. The introduction of this practice by Lister effected a complete change in operative surgery. The dark times of suppurating wounds, of foul discharges, of secondary haemorrhage, of pyaemic abscesses and hospital gangrene constitute what is now spoken of in surgery as the pre-Listerian era.
As years went on, surgeons tried to simplify and improve the somewhat complicated and expensive measures and dressings and chemists were at pains to supply carbolic acid in a pure form and to discover new antiseptics, the great object being to get a non-irritating antiseptic which should at the same time be a powerful germicide. Iodoform, oil of eucalyptus, salicylic acid, boracic acid, mercuric iodide, and corrosive sublimate were used.
For some years Lister irrigated a wound with carbolic lotion during the operation and at the dressings when it was exposed, but the introduction of the spray displaced the irrigation method. All these different procedures, however, as regards both the antiseptic used and the best method of its application in oily and watery solutions and in dressings, were subsidiary to the great principle involved—namely, that putrefaction in a wound is an evil which can be prevented, and that, if it is prevented, local irritation, in so far as it is due to putrefaction, is obviated and septicaemia and pyaemia cannot occur. Alongside of this great improvement the immense advantage of free drainage was universally acknowledged. Moreover, surgeons at once began to take greater care in securing the cleanliness of wounds, and some of them, Lawson Tait and Bantock, for example, produced such excellent results by the adoption merely of methods of strict cleanliness, and became so aggressive in their championship of them, that many of the older practitioners were bewildered and unable to decide as to where truth began and where it ended in the new doctrine. But though the actual methods, as taught and practised by Lister, have, with the spray-producers, passed away and given place to new, still the great light which he shed in the surgical world burns as brightly as ever it did, and all the methods which are practised to-day are the direct results of his teaching.
By 1885 the carbolic acid spray, which to some practitioners had apparently been theiembodiment of the Listerian theory and practice, was beginning to pass into desuetude, though for a good many years after that time certain surgeons continued to employ it during operation, and during the subsequent dressings of the wound. Surgeons who, having had practical experience of the unhappy course which their operation-cases had been apt to run in the pre-Listerian days, and of the vast improvements which ensued on their adoption of the spray-and-gauze method in its entirety, were, not unnaturally, reluctant to operate except in a cloud of carbolic vapour. So, even after Lister himself had given up the spray, its use was continued by many of his disciples. It was in the course of 1888 that operating surgeons began to neglect the letter of the antiseptic treatment and to bring themselves more under the broadening influence of its spirit. Certain adventurous and partially unconvinced surgeons began to give up the carbolic spray gradually, by imparting a smaller percentage of carbolic acid to the vapour, until at last the antiseptic disappeared altogether, apparently without detriment to the excellence of the results obtained. But while some surgeons were thus ceasing to apply the antiseptic spray to the wound during operation, others were pouring mild carbolic lotion, or a very weak solution of corrosive sublimate (an extremely potent germicide) over the freshly-cut surfaces. These measures were in turn given up, to the advantage of the patient; for it was hardly to be expected that a chemical agent which was strong enough to destroy or render inert septic micro-organisms in and about a wound would fail to injure exposed and living tissues. Eventually it became generally admitted that if a surgeon was going to operate upon the depths of an open abdomen for an hour or more, the chilling and the chemical influences of the spray must certainly lower the vitality of the parts exposed, as well as interfere with the prompt healing of the wounded surfaces. With the spray went also the “protective,” the paraffin gauze, and the mackintosh sheeting which enveloped the bulky dressing.
Years before this happened, in the address on surgery given at the Cork meeting of the British Medical Association, Sir Aseptic Surgery. William (then Mr) Savory had somewhat severely criticized the rigid exclusiveness of the members of the spray-and-gauze school: the sum and substance of the address was that every careful surgeon was an antiseptic surgeon, and that the success of the Listerian surgeon did not depend upon the spray or the gauze, or the two together, but upon cleanliness—that the surgeon's fingers and instruments and the area operated on must be surgically clean. Though precise experiments show that it is impossible for the surgeon to remove every trace of septicity from his own hands and from the skin of his patient, still with nail-brush, soap and water, and alcohol or turpentine, with possibly the help of some mercuric germicide, he can, for all practical purposes, render his hands safe. Recognizing this difficulty many surgeons prefer to operate in thin rubber gloves which can, for certain, by boiling, be rendered free of all germs; others, in addition, put on a mask, sterile overalls, and india-rubber shoes. But these excessive refinements do not seem to be generally acceptable, whilst the results of practice show that they are by no means necessary. The careful, the antiseptic surgeon of 1885 is to-day represented by the careful, the aseptic surgeon. The antiseptic surgeon was waging a constant warfare against germs which his creed told him were on his hands, in the wound, in the air, everywhere—and these he attacked with potent chemicals which beyond question often did real damage to the healthy tissues laid bare during the operation. If, as was frequently the case, his own hands became sore and rough from contact with the antiseptics he employed, it was not to be wondered at if a peritoneal surface or an incised tissue became more seriously affected. The surgeon of to-day has much less commerce with antiseptics: he operates with hands which, for all practical purposes, may be considered as germless; he uses instruments which are certainly germless, for they have just been boiled for twenty minutes in water (to which a little common soda has been added to prevent tarnishing of the steel), and he operates on tissues which have been duly made clean in a surgical sense. If he were asked what he considers the chief essentials for securing success in his operative practice, he would probably reply, “Soap and water and a nail-brush.” He uses no antiseptics during the operations, he keeps the wound dry by gently swabbing it with aseptic, absorbent cotton-wool, and he dresses it with a pad of aseptic gauze. This is the simple aseptic method which has been gradually evolved from the Listerian antiseptic system. But though the pendulum has swung so far in the direction of aseptic surgery, a very large proportion of operators still adhere to the antiseptic measures which had proved so highly beneficial. The judicious employment of weak solutions of carbolic acid, or of mercuric salts, and the application of unirritating dressings of an antiseptic nature cannot do any harm, and, on the other hand, they may be of great service in the case of there having been some flaw in the carrying out of what should have been an absolutely aseptic operation.
A great change has taken place in connexion with the use of soft india-rubber drainage-tubes. In former years most Drainage-tubes. surgeons placed one or more of these in the dependent parts of the area of operation, so that the blood or serum oozing from the injured tissues might find a ready escape. But to-day, except in dealing with a large abscess or other septic cavity, many surgeons make no provision for drainage, but, bandaging the part beneath a pad of aseptic wool, put on so much pressure that any little leakage into the tissues is quickly absorbed. If a drainage-tube can be dispensed with, so much the better, for if it is not actually needed its presence keeps up irritation and delays prompt healing. But inasmuch as a tube if rightly placed in a deep wound is an insurance against the occurrence of “tension,” and as it can easily be withdrawn at the end of twenty-four hours (even if it has served no useful purpose), it is improbable that the practice of drainage of freshly made cavities will ever be entirely given up. If the tube is removed after twenty-four hours its presence can have done no harm and sometimes the large amount of fluid which it has drained from the wound affords clear evidence that its use has saved the patient discomfort and has probably expedited his recovery. For septic cavities drainage-tubes are still used, but it must be remembered that the tube cannot remain long in position without causing and keeping up irritation; hence, even in septic cases, the modern surgeon discards the tube at the earliest possible moment. If after he has taken it out septic fluids collect, and the patient's temperature rises, it can easily be reinserted. But it is better to take out the tube too soon than to leave it in too long; this remark applies with special force to the treatment of abscess of the pleural cavity (empyema), in the treatment of which a drainage-tube has almost certainly to be employed.
Poultices are now never used: they were apt to be foul and offensive, and were certainly septic and dangerous. If moisture and warmth are needed for a wound they can be obtained by the use of a fold of clean lint, or by some aseptic wool which has been wrung out in a hot solution of boracic or carbolic acid, and applied under some waterproof material, which effectually prevents evaporation and chilling. There was no special virtue in poultices made of linseed meal or even of scraped carrot: they simply stored up the moisture and heat. They possessed no possible advantage over the modern fomentation under oil-silk.
Much less is heard now of so-called “bloodless” operations. The bloodlessness was secured by the part to be operated on—an Bloodless Operations. arm, for instance—being raised and compressed from the fingers to the shoulder by successive turns of an india-rubber roller-bandage (Esmarch's), the main artery of the limb being then compressed by the application of an elastic cord above the highest turn of the bandage. The bandage being removed, the operation was performed through bloodless tissues. But when it was completed and the elastic cord removed from around the upper part of the limb, a reactionary flow of blood took place into every small vessel which had been previously squeezed empty, so that though the operation itself had actually been bloodless, the wound could not be closed because of the occurrence of unusually free haemorrhage or troublesome oozing. A further objection to the application of such an elastic roller-bandage was that septic or tuberculous material might by chance be squeezed from the tissues in which it was perhaps harmlessly lying, forced into the blood vessels, and so widely disseminated through the body. Esmarch's bandage is therefore but little used now in operative surgery. Instead, each bleeding point at an operation is promptly secured by a small pair of nickel-plated clip-forceps, which generally have the effect, after being left on for a few minutes, of completely and permanently arresting the bleeding. These clips were specially introduced into practice by Sir Spencer Wells, and it is no unusual thing for a surgeon to have twenty or thirty pairs of them at hand during an extensive operation. Seeing how convenient, not to say indispensable, they are in such circumstances, the surgeon of to-day wonders how he formerly managed to get on at all without them.
Biers's treatment by passive congestion is carried out by gently assisting the return of venous blood from a part of the body without in any way checking the arterial flow. In the case of tuberculous disease of the knee-joint, for instance, an elastic band is gently placed round the thigh for several hours a day, and in disease of the wrist or elbow the girth is applied round the arm. The skin below becomes flushed, and the arterial blood which, as shown by the pulse, is still flowing into the affected part, is compelled to linger in the affected tissues, giving the serum and the white corpuscles time to exert their beneficial influence upon the disease.
In the case of tuberculous, or septic, ahectionsof the lymphatic glands of the neck, or of other parts where the constriction cannot be conveniently obtained, effective congestion can be secured by the use of cupping glasses. And if so be that suppuration is taking place in the interior of an inflamed gland, the cupping-glasses can be applied after a small puncture has been made into the softened part of the gland. In this way the whole of the broken-down material can be got away without the necessity of making an actual incision or of resorting to scraping. The method of inducing hyperaemia should be so conducted as to give the patient no pain whatever: it must not be carried out with excessive energy.
By means of the Rontgen or X-rays (see X-Ray Treatment) the surgeon is able to procure a distinct shadow-portrait of Röntgen Rays. deeply-placed bones, so that he can be assured as to the presence or absence of fracture or dislocation, or of outgrowth of bone, or of bone-containing tumours. By this means also he is able to locate with absolute precision the situation of a foreign body in the tissues—of a coin in the windpipe or gullet, of a broken piece of a needle in the hand, of a splinter of glass in the foot, or of a bullet deeply embedded in soft tissues or bone. This effect may be obtained upon a fluorescent screen or printed in a permanent form upon glass or paper. The shadow is cast by a 10- or 12-in. spark from a Crookes vacuum tube. The rays of Röntgen find their way through dead and living tissues which are far beyond the reach of the rays of ordinary light, and they are thus able even to reveal changes in the deeply placed hip-joint which have been produced by tuberculous disease. In examining an injured limb it is not necessary to take off wooden splints or bandages except in cases where the latter have been treated with plaster of paris, lime-salts obstructing the rays and throwing a shadow. Thus the rays may pass through an ordinary uric acid calculus in the kidney or bladder; but if it contains salts of lime, as does the mulberry calculus (oxalate of lime), a definite shadow is cast upon the screen. The value of the X-rays is not limited to the elucidation of obscure problems such as those just indicated: they are also of therapeutic value; for example, in the treatment of certain forms of skin disease, as well as of cancer.
Too much, however, must not be expected from them. For the treatment of a patch of tuberculous ulceration (lupus), or for a superficial cancerous sore (epithelioma), they may be of service, but in the treatment of a deeply-seated malignant growth—as a cancer of the breast—they have not proved of value. Moreover, the X-rays sometimes cause serious burns of the skin; and although this happens less often now than was previously the case, still the frequent application of the rays is apt to be followed by cutaneous warty growths which are apt in turn to develop into cancer. In many cases in which the X-rays are used a more prompt and efficient means of treatment would probably be by excision. One great advantage which operative treatment by the knife must always have over the treatment by X-rays is that the secondary implication of the lymphatic glands can be dealt with at the same time. And this, in many cases, is a matter of almost equal importance to that of removal of the cancer itself.
The employment of radium in surgery is still in its infancy. Doubtless radium is a very powerful agent, but even if it were Radium. found of peculiar value in treatment its cost would, for the present, put it out of the reach of most practitioners. Probably it will be found useful in the treatment of naevus, rodent ulcers and superficial malignant growths. As to what influence radium may have in the treatment of deeply-seated cancers it is as yet impossible even to guess. For those sad cases, however, which the practical surgeon is reluctantly compelled to admit as being beyond the reach of his operative skill, the influence of radium should be tried with determination and thoroughness. The therapeutic influence of radium may eventually be found to be great, or it may be disappointing. The fact that under direct royal patronage an institution has been established in London for the investigation of the physical and therapeutic value of this newly discovered agent should satisfy every one that its properties will be duly inquired into and made known without mystery or charlatanism and absolutely in the interest of the people. But in the meanwhile too much must not be expected from it as a surgical agent. (E. O.*)