PART II. PRACTICE OF SURGERY

SECTION IV. OPERATIVE SURGERY

Part 16. Introduction. Recent Developments.

Range of Within recent years the main advance in surgery has surgical keen fr0m the scientific side, due to increased precision in tionT" physiological knowledge and a careful study of the relation of organisms to various diseased conditions. And with this progress operative skill, in many directions previously unthought of, has kept pace. Cranial operative surgery has advanced as the motor areas on the surface of the brain have been localized with greater precision. The ex-perimental physiologist has done his part; the clinical observer is now doing his. Cranial surgery necessitates special notice. In the thoracic cavity also diseased con-ditions are now relieved by surgical operations. The greatest advance of all, however, is in connexion with the abdominal cavity. Under this head the work of the last thirty years requires special notice. The peritoneum was at one time considered a closed book to the operator; now all is changed, and abdominal surgery has become one of the most important branches of operative work. Joints in a state of inflammation are also now freely opened and tension is relieved. With the relief of tension the in-flammatory process subsides and the joint recovers. The excision of diseased joints has also become part of the everyday work of the surgeon. Cancerous affections—using the term in a clinical sense—of the tongue, rectum, and larynx are now treated by excision of these organs. But it is still a question in what cases the operation prolongs life, and what cases are specially suited for operation. While greater latitude has been given to surgical interference with the different cavities of the body, operations upon the limbs have been restricted in consequence of the ac-ceptance of Lister's views with regard to wound treatment. Many limbs upon which formerly amputation was per-formed, as, for example, in the case of compound fractures, Conser- are now saved. The term "conservative surgery," which vative formerly had reference to the excision of a diseased joint surgery. jngtea¿ 0f amputation of the affected limb, has now a wider meaning, and covers not only the different excisions which have taken the place of amputation but also those cases in which a limb is saved by careful antiseptic man-agement after severe injury. At one time, perhaps, in the early stages of antiseptic wround treatment the brilliancy of the results obtained by these means, and the immunity which resulted from the prevention of blood-poisoning, en-couraged surgeons to save a limb which, when the wound was healed, was not really useful. An upper limb saved, however inefficient, is better than any artificial substitute, and every endeavour in the direction of conservation should be made. Conservation in the case of a lower limb, on the other hand, may be carried too far. Unless the saved limb cü,n support the weight of the body, it is far better to per-form amputation, because a satisfactory artificial substitute can be found to take the place of the lower extremity. In performing amputation on a lower limb every endeavour should be made to obtain a stump which will bear, in part at any rate, the weight of the patient's body. Since the Modern introduction of anaesthetics rapidity in performing an surgical amputation is not essential. Flaps can be carefully made; Jj™6* time can be taken to shape them; and they can be so arranged that the resulting cicatrix -will not be opposite the sawn extremity of the bone. In order to obtain such flaps the surgeon is justified in sacrificing to some extent the length of the limb, if by so doing he can leave a mobile and painless stump on which an artificial limb can be comfortably fitted. But this does not hold good to the same extent for an upper limb. The pressure on the ex- tremity is not so great, and the longer the stump the more easily can an artificial substitute be fitted on. As a result also of Lister's teaching operative procedure for the cure of various deformities, such as knock-knee, rickets, and club-foot, in which the bones affected are freely attacked, has done much to relieve unsightly deformity and increase the usefulness of the individual. In all operations absorb- able catgut ligatures for the cut vessels have since about 1861 taken the. place of silk, which had to come away by ul- ceration,—a destructive process antagonistic to rapid heal- ing. Greater care is taken to save blood by emptying the part to be operated on before beginning the operation. Greater care is also taken to tie all bleeding points, so as to prevent reactionary haemorrhage and the escape of blood between the surfaces of the wound, whereby healing is retarded. Free drainage by india-rubber and glass tubing, by absorb- able tubes made of decalcified bone, by skeins of catgut acting by capillarity—all the outcome of an understanding of the local irritation and constitutional fever caused by tension—have done more than anything else to enable the surgeon to attain his triple object,—painlessness, rapidity, and safety in the healing of a wound. Lastly, the clear understanding of the term " antiseptic " in its fullest mean- ing, the knowledge of the power which the unirritated and healthy tissues have as germicidal agents, and the introduction of various antiseptic or rather antitheric sub- stances, some of which destroy, some of which paralyse, those lowly organisms whose power for evil in an un- healthy tissue or an injured part is so great, contribute towards the same great end. By these means operations are to a great extent relieved of their dangers, and by anaesthesia, which prevents pain and suffering, they are robbed of their terrors. (j. c.)





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