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fortiori he may be commanded to find sureties, and be committed for not doing it.

SURGERY is that division of the heal. ing art, which is chiefly conversant with the treatment of the external and local disorders of the body, of the effects of accidental injury, and of such diseases in general as are curable by manual operation. Yet its field is not entirely confined to the department just alluded to; since local disorders, and particularly accidents, often affect the whole frame, so as to induce a general derangement of the constitution; and again, diseases of parts arise out of constitutional affections, or, although originally independent, may be greatly aggravated by them. Hence it is obviously necessary that the surgeon should be acquainted with the nature and treatment of such general disorders; and consequently, in marking out the limits which divide the departments of the surgeon and physician, it is hardly possible to attain such a pitch of accuracy, as to prevent all supposed encroachment of either side on the province of the other. The care of the external and local affections of the human body was, in the infancy of science, a branch of the art of medicine. Surgery and physic were then, and for many ages afterwards, practised by the same individuals. These, however, in course of time, began to consider the manual and operative part of the profession as too mechanical and low for persons of their scientific education, and consequently resigned them to an inferior class of uneducated men, who generally combined with them the trade of the barber. Hence arose, in most countries of Europe, the calling of barber-surgeon; which included, besides shaving, hair dressing, &c. tooth drawing, bleeding, dressing of ulcers, and other of the more common and easy parts of operative surgery. While contaminated by so degrading an alliance, and practised by persons wholly illiterate, we cannot be surprised to find that surgery and its professors met with neglect and contempt, and that the latter were considered as merely subordinate to the physicians. The barber-surgeons must still have had opportunities of seeing and learning disease; they began to get an insight into the structure of the human body, and they acquired a respectability, by being employed in wars in the cure of the wounded. The physicians, who were still the only regularly educated and scientific class of men practising the art of healing, wished to retain their

old and long enjoyed superiority; and hence arose in many countries long and sharp disputes with the barber-surgeons, which ended at last, as the progress of civilization and improvement would naturally lead us to expect, in the separation of the barbers and surgeons, and the elevation of the latter to their proper rank and consideration in society.

Whatever part of the subject we may contemplate, we shall find that the art of surgery requires, no less than that of physic, all the advantages that can be de. rived from the most liberal education; that it demands still more imperiously a fami liar knowledge of anatomy and physiolo gy, i. e. of the structure and functions of that machine, whose derangements it proposes to remedy; and consequently, that although prejudice still assigns to the physician a superior rank to that of the surgeon, they must be considered, in modern days, as equals, whether we regard the reason of the thing, or proceed to an actual comparison of individuals.

Our opinions concerning the education and qualifications of the surgeon will be easily collected from the foregoing observations. Instead of spending seven years of the most valuable part of his life in the drudgery of an apothecary's shop, the youth destined for the profession of surgery should receive a learned and liberal education. The Latin language among the dead, and the French of the living, are indispensably necessary; and the German would form a very useful addition to these.

Anatomy and physiology are the next objects of attention, and demand the most assiduous cultivation; these sciences are the foundation on which the art of surgery rests. The study of chemistry and natural philosophy will be pursued at the same time. When prepared by these previous steps, the student may commence the practical part of his education in the large hospitals of the metropolis; carefully studying diseases them. selves, taking notes of the most interesting cases, and omitting no opportunity of observing the alterations occasioned by disease in the structure of the body.Lectures on surgery, on the materia medica, and the practice of medicine, must also be attended. The performance of surgical operations on the dead body will be highly beneficial, as leading to the study of those parts of anatomy, which are more particularly concerned in operations, and as imparting the manual skill necessary to the operator.

Of systematic works on surgery, there is none which unites the recommendations of clearness, shortness, and compre. hension, to so great a degree, as the "First lines of the Practice of Surgery," by Mr. S. Cooper, to which we therefore refer the reader. The larger systems are by no means unexceptionable; we may mention that of Latta; the "Systema Chirurgia hodierna" of Callisen ; and the "Anfangs-grunde der Wundarzney kunst" of Richter. Generally, however, the works that treat of particular subjects are to be preferred to the systems of surgery. The writings of Mr. Pott, and the "Memoirs of the French Royal Academy of Surgery, contain a great deal of valuable information; as also do those of John Hunter, Home, Abernethy, and Astley Cooper; Le Dran, Sharp, Bertrandi, and Sabatier, may be read on the opera. tions. The numerous other sources of surgical knowledge will be discovered by the student in his progress. The following sketch will be divided into general surgical subjects, or such disorders as are common to several situations in the body, including also the constitutional derange. ments which accompany or cause local disorders; and particular surgical subjects, or the disorders and injuries of each particular part, and the operations practised on it. As the limits between surgery and medicine are rather artificial than real, these two branches of medical science touch each other in various points, and the physician and surgeon both claim a right to undertake the management of the same disorder. Hence the article MEDICINE of this work contains remarks on several diseases which are often treated by the surgeon; and we refer the reader to that article on the following points, viz. fever, tetanus, rachitis, scrofula, amaurosis, albugo, deafness, enuresis, ischuria, herpes, tinea, and psora.

GENERAL SURGICAL SUBJECTS.

Sympathetic Fever. No part of the animal body can be very considerably disordered, without occasioning a correspondent derangement of the whole constitution.

Such disorder has been considered by Mr Hunter as the result of universal sympathy. This consent of the whole constitution with its parts manifests itself in particular instances, by a greater disturbance of the functions of some organs than of others; and from this circumstance these diseases have derived the appella

tions by which they are commonly dis. tinguished. If the actions of the sangui ferous system be principally disturbed, and the temperature of the body subject to unnatural variations, the disease is termed fever; if the nervous system be chiefly affected, a state of vigilance or delirium may be produced; convulsions and tetanus take place, when the muscular system is more particularly disordered. Though the especial disorder of particular organs thus gives a character and denomination to the disease, it is sufficiently evident, in every instance, that the whole constitution is disturbed.

The fever which accompanies local accident or disease has been termed symptomatic, as if it were one of the symptoms of the local disorder; the epithet sympathetic is preferable, as it is founded on the real nature of the disorder, viz. a sympathy of the whole constitution for the disturbed state of a part.

The sympathetic inflammatory fever is accompanied with a frequent, strong and full pulse, hot and dry skin, scanty and high coloured urine, dry furred tongue, thirst, loss of appetite and sleep in some cases delirium.

When the local affection is in such parts as are essential to life, the powers of the constitution seem to be much depressed; and the pulse is frequent and small.

Treatment. The cure of the local inflammation which excites and keeps up this sympathetic disturbance of the whole constitution, is the most effectual step for stopping the general disorder. But as the fever may react on the local disorder, palliative means may be necessary for the constitutional symptoms. Bleeding, saline purgatives, and diaphoretics, as the preparations of antimony, and the aqua ammoniæ acetatæ, are the best means. The use of the lancet is only advisable where the local mischief is to be feared on account of its situation or extent.

The sympathetic fever, just described, is produced by the irritation of a local injury upon a healthy constitution; when, however, the disease has continued unsubdued for a long time, the constitution still sympathizes, although in a different manner; and the disorder then produced is called the sympathetic hectic fever. This form of constitutional sympathy attends such local affections as debilitate and harass the frame; and it is the reactive effort of an irritated and weakened constitution. The symptoms are, a frequent, small pulse, moist skin, pale and

copious urine, great weakness, moist tongue, deficient appetite, often sickness, nocturnal sweats, loss of sleep, indigestion, &c.

Treatment. The alleviation or removal of the local complaint is the most effectual remedy. When this cannot be accomplished, we must try to strengthen the patient; and if there were a medicine possessing the direct power of communicating strength to the constitution, these cases would be very proper for its employment. Particular symptoms may be combatted, so as to keep all the functions in a state approaching as nearly as we can to that of health, and digestion pronoted. Bark, with gentle cordial and aromatic draughts, are the most proper medicines. The food should be light and nourishing, and taken frequently in small quantities. Opium is often of great service, both in procuring sleep, and in checking the purging.

Disorder of the digestive Organs. The stomach and bowels bear a considerable share in the sympathetic derangements already considered. But in many instances of local complaints they are deranged in a still more striking way; and again, a disturbed state of these organs, arising from various causes, will either give ori. gin to various obstinate local complaints, or very much increase the difficulty of their cure. Many observations connected with this subject are scattered in the works of surgical writers; but the public are indebted for a general, scientific, and original view of the whole subject, to Mr. Abernethy; to whose surgical observations we must refer the reader.

The symptoms of disordered digestive organs, whether induced by the irritation of local disease, or by other causes, as sedentary life, impure air, anxiety, and too great exertion of mind or body, are, diminution of the appetite and digestion, flatulence, and unnatural colour and fetor of the excretions, which are generally deficient in quantity. The tongue is dry, whitish, and furred, particularly at the back part, and this symptom is most apparent in the morning. As the disease advances, a tenderness is felt on pressing the epigastric region, and the urine is frequently turbid. Mr. Abernethy considers this affection to be a general disorder of all the organs concerned in the assimilation of our food; and that it consists in a weakness and irritability of the affected parts, accompanied by a deficiency or depravity of the fluids secreted by them; upon the heal

thy qualities of which the right performance of their functions seems to depend. The duration of the affection without fatal consequences, or indeed without any changes of structure in the parts, shows that it is only a disorder of functions.

When it is considered that this derangement of the chylopoietic viscera may bring on various diseases, and that local affections, occurring during its existence, will become peculiar in their na ture and progress, and difficult of cure, the importance of the subject will be readily allowed. A particular attention to diet is a point of primary importance in the treatment; and connected with this, the practice of taking five grains of powdered rhubarb an hour before dinner is very beneficial. A correction of any obvious irregularity in the intestines, and a regular diurnal evacuation of them, are the next points to which we must attend. Purging is by no means advisable in the weakened state of these organs. The administration of small doses of mercury every night, or every other night, has a powerful effect in correcting disorders of the biliary secretion, and consequently in bringing the stools to their natural colour. Vegetable diet drinks, as the decoct. sarsaparill, comp. have been advantageously combined with these means. The cause of the disorder may be more completely relieved by good air, exercise, and mental tranquillity, while the medical assistance above mentioned counteracts the effects. By such simple treatment as we have just mentioned, obstinate and extensive local diseases of the most opposite classes, which have resisted all the ordinary methods, will often be either entirely cured, or very signally relieved.

Tetanus, or lock jaw, is one of the most alarming consequences of local injury. It is most frequent in warm climates, in the male sex, and in the robust and vigorous. It does not appear till many days after the accident, and frequently when the wound is quite healed. Injuries of the fingers and toes are its most frequent causes.

Symptoms. The muscles of the lower jaw first become stiff, and then rigidly contracted, so that the mouth cannot be opened. Those of the neck, back, and whole body, are successively affected in the same manner. The spasm, however, is not constant, as violent and most painful convulsions occasionally agitate the whole frame. The progress is various;

when rapid, the patient scarcely ever recovers; but if he survive the fourth day, the prognostic is much more favourable. The vital functions are but little affected. Treatment. When the symptoms have come on, there seems to be no connection between them and the original local cause; so that no assistance can be derived from this source. Opium in very large doses, as a grain in two hours, and then gradually increased; and the same remedy by the way of clyster, and in frictions, seems to have afforded the most relief The warm bath, camphor, volatile alkali, and musk, according to circumstances. Large quantities of wine have been recommended; and in some cases the cold bath during the spasm has relieved. Salivation is useless.

Inflammation, in some of its states or varieties, is presented to our view in almost every surgical disease, and consequently particularly demands the attention of the surgeon. It occurs as a natural means of cure in many species of accidental injury; and here it is considered as healthy it may also be regarded in the same light, where it follows any local irritation in a healthy constitution and part. In other cases it is complicated with some morbid tendency, as in erysipelas, scrophula, lues venerea, &c. and hence arise numerous species of unhealthy inflammation. Again, it may be acute or chronic, in respect to its duration.

Healthy acute inflammation has been called phlegmon. Its symptoms are, preternatural redness, increased heat, and a circumscribed, throbbing, painful swelling of the inflamed part. The exciting cause is generally some external violence, of a mechanical or chemical nature. Sometimes it arises spontaneously; or, in other words, no perceptible cause can be assigned for it. The proximate cause is, an increased action of the vessels of the part.

During its existence in any important organ of the body, blood taken away from the system, has the inflammatory crust, or buff, on the upper surface of the clot, which is at the same time concave or cupped.

Treatment. 1. Removal of the cause, where that is practicable. 2. Bleeding, both topical and general. The latter is only necessary when the inflammation of the organ endangers life itself, as the brain, lungs, liver, &c.; or when the part has inferior powers of recovery, as a joint; or where suppuration would entirely destroy the organ, as in ophthal

my. The former is effected by means of leeches or cupping. 3. Purgatives, chiefly of the saline kind, as Glauber's and Epsom salts, &c. 4. Antimonial medicines, which relieve the skin, and diminish febrile action. 5. Reduced diet, including abstinence from fermented or spirituous liquors, and animal food. 6. Evaporation constantly kept up from the surface by folded cloths, wetted with cold washes. This is very powerful in reducing the heat and increased actions of the part. A solution of ceruss. acetat. 3ss. in Ziv. of vinegar and ij. of distilled water is a very good application. Where, on account of concomitant extravasation of blood, as in bruises, it is desirable to excite the absorbents, washes supposed to have this effect, and therefore termed discutients, are employed: such as R. ammon. muriat. ss. aceti et spir. vin. rectif. aa Hj. 7. Warm applications, as poultices, or fomentations, occasionally relieve, when the cold washes are ineffectual.

Inflammation terminates in resolution, which is the gradual subsidence of all the symptoms; in suppuration, or the forma tion of matter; or in mortification.

Suppuration. The inflammatory symptoms, instead of yielding to the treatment, are aggravated; and afterwards suddenly subside, the patient being seized with shiverings. The swelling becomes softer, and white at its most elevated part; and if the collection be superficial, a fluctuation can be felt. At this time a fluid, called matter, or pus, is contained in a cavity formed in the centre of the inflamed part, and termed an abscess. This peculiar fluid is separated from the blood by the inexplicable power of the secerning arteries, just as ordinary secretion takes place. In a healthy state it is a homogenous, light, yellow fluid, about the consistence of cream, and possessing little smell: but under many circumstances of disease, its appearance and properties are entirely changed. The cyst, containing the pus, has a smooth and somewhat villous surface: it seems to be lined with a layer of coagulating lymph, thickened and agglutinated by the inand the surrounding cellular substance is flammation, so as to prevent the matter from spreading. From the arteries of this part the pus is secreted.

The matter always makes its way towards the external surface of the body, even if the parts should be very much

thinner and less resisting towards any cavity.

Treatment. A soft poultice, until the abscess bursts, or has been opened. The latter operation is performed by a straight two-edged scalpel, or an abscess lancet. It is not necessary, unless the collection be under a fascia, which may prevent it from coming forwards; or near a joint, or large cavity of the body, as the belly or chest. A poultice should still be applied after the bursting of the abscess.

Mortification ensues when the violence of the inflammation, or its duration, has completely exhausted the powers of the part. The pain subsides; the part becomes livid, or otherwise discoloured; the cuticle is elevated into a vesication by a turbid fluid; the pain and tension are diminished, and air is disengaged into the cellular substance, so as to cause a crackling sensation. To this stage the term gangrene is applied; but when the part has become quite black, and has lost its motion, sensation, and heat, it is called sphacelus.

The blood coagulates in the large vessels leading to the part, and consequent ly the separation of the limb is not followed by hemorrhage.

But mortification often occurs without preceding inflammation in parts and subjects where there is great weakness. Tying the artery of a limb; impeding the return of the venous blood; continued topical pressure in a weak constitution; cold, when followed by the opposite extreme; are causes of this description. A peculiar mortification, beginning at the toes of old persons, and proceeding upwards, is of this kind.

When the mortification has stopped, a defined boundary separates the dead and living parts; the lymphatics remove the connecting matter, so as to form a groove, in which suppuration commences; and this groove extends deeper and deeper, until complete separation is effected. Our treatment must be directed to the object of stopping the disorder; in which view attention to the constitutional disturbance, that is usually very great, is of primary importance. The state of the digestive organs will demand particular attention. The great pain frequently requires opium. Cold washes while the inflammation continues high; and after wards a poultice of bread or linseed, alone, or in combination with very finely powdered charcoal, are the best topical means. Amputation of a limb can never be allowed, until the line of separation

between the dead and living parts is clearly formed. When the inflammation is abated, and the separation is going on, (which should in general be left entirely to nature,) the constitution should be strengthened by every means both of food and diet. Hence bark, with wine and aromatic confection; fermented liquors, and a nourishing diet, become proper. Bark, however, is by no means so universally beneficial in mortification as many surgeons suppose: if sympa thetic inflammatory fever be present, or derangement of the chylopoietic organs, it would certainly be hurtful; but, where debility shews itself, this remedy must be instantly employed. Opium is often very serviceable; and it has been represented by Mr. Pott as almost a specific in the mortification of the toes and feet of old persons, where it must be used in a very free way. The same remedy will be of service in other cases, where the disorder is preceded and accompanied with great pain, but not inflammation.

Erysipelas is a species of superficial inflammation, in which the red colour is tinged more or less with yellow, particularly towards the termination; it spreads rapidly and widely; there is swelling, without much elevation, hardness, or circumscription. The skin is glossy, and its colour disappears on pressure. The pain is of a burning or itching kind. It often changes its seat; and is attended, when it recovers, with desquamation of the cuticle. Sometimes vesicles are formed. It seldom suppurates; but when it does, the abscesses are very extensive, as adhesions seldom take place, to limit the expansion of the matter. Mortification ensues in some instances.

The constitutional affection varies considerably, according to the degree of local disturbance. Langour, head-ache, loss of appetite, nausea, vomiting, oppression of the stomach, and foul taste in the mouth, precede. It is most dan gerous in the face, and attended with the greatest disturbance, often amounting to delirium.

Disorders of the chylopoietic viscera, and suppressed perspiration, are the most prominent causes of the complaint. Mild purgatives, diaphoretics, and the antiphlogistic regimen, are sufficient in the slighter cases. In more severe attacks, calomel, combined with other purges, and antimonials, is proper. Emetics, where the stomach is much distressed. Bark may be required after the disorder

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