Elements of Surgery. Robert Liston

      The functions and structure of parts are more frequently preserved uninjured—mutilation is more rarely required—and operations are dispensed with. The wider the extension of pathology, the fewer the operations will be—thus affording the best criterion of professional attainment. Who will question, that there is more merit in saving one limb by superior skill, than in lopping off a thousand with the utmost dexterity?

      To treat surgical diseases as they ought to be treated, the practitioner must be thoroughly acquainted with the healthy and morbid structure; he must also have a mind vigorous and firm from nature, well instructed in the best precedents, and matured by observation.

      Years are not the measure of experience. It does not follow, that the older the surgeon is, the more experienced and trustworthy he must be. The greatest number of well-assorted facts on a particular subject constitutes experience, whether these facts have been culled in five years or in fifty.

      It is only from experience, directed and aided by previous study, that accuracy of diagnosis and celerity of decision can be acquired. Besides knowing in what manner to proceed, the surgeon must know well wherefore he acts, and also the precise time at which he should interfere. With knowledge and confidence derived from experience, he will perform such operations as are indispensable for the removal of pain and deformity, or for the preservation of life, with calmness and facility—with safety to his patient, and satisfaction to those who assist in, or witness, his proceedings.

      Attention to the apparatus is necessary. It should be in good order, simple, and ample. The young surgeon should note down, previously to an operation, whatever, on reflection, can possibly be required. "For in most capital operations, unforeseen circumstances will sometimes occur, and must be attended to; and he who, without giving unnecessary pain from delay, finishes what he has to do in the most perfect manner, and that most likely to conduce to his patient’s safety, is the best operator."

      It is seldom necessary to employ much preliminary treatment. From the usual preparative course of bleeding, purging, cooling diet, etc., patients about to undergo capital operations, as lithotomy, suffer more than they can gain.

      It is of the utmost importance to attend to the state of the patient’s mind and feelings. He ought not to be kept in suspense, but encouraged and assured; and his apprehensions must be allayed. If this cannot be effected—if he is dejected and despondent—talks of the great risk, and of the certainty of his dying, it is better that the operation be abandoned, or at least delayed. If, on the contrary, he is confident in the resources of his constitution, and in the ability of his attendant, and looks forward to the advantage to be derived from his own fortitude, then should there be no delay.

      A mild laxative may be given, when an empty state of the bowels is desirable, or when they, by acting too soon afterwards, might put the patient to inconvenience or pain, or interrupt the curative process.

      Attention to after-treatment is of much greater importance. The practitioner is not to rely on success, however well the manual part has proceeded. He must consider his labour only begun, when the operation has finished; the patient is yet to be conducted, by kindness and judgment, through the process of cure.

      It is thus only that difficult and unpromising cases can be brought to a happy conclusion, and favour and lasting reputation gained.

      In the present work an endeavour has been made, in the first place, to lay down, correctly and concisely, the general principles which ought to guide the practitioner in the management of constitutional disturbance, however occasioned.

      The observations introduced to illustrate the doctrines inculcated are given as briefly as is consistent with an accurate detail of symptoms and results. The descriptions of particular diseases have been sketched and finished from nature; and, it is hoped, with such fidelity, that their resemblance will be readily recognised.

      To describe all the methods recommended and followed, in the different surgical operations, would occupy more space than can be allotted in an elementary work—would, without answering any good purpose, lead into the wide range of the history and progress of surgery.

      Such modes of operating are described as have been repeatedly and successfully performed by the Author.

      If by clear and simple description of the phenomena attendant on morbid action, and of the changes which it produces,—if by plain rules for the treatment of the diseases, and performing the operations for their alleviation or cure,—he contribute to the progress of surgery, and the consequent diminution of human misery, he will consider himself fully rewarded for the time and the labour spent on this production.

PART FIRST.

       OF INFLAMMATION.

       Table of Contents

      There are few accidents or diseases, to which the human body is liable, which are not preceded or followed by incited action, increased circulation, and accumulation of blood in the capillary vessels of the part affected; and these phenomena require to be very attentively studied, and correctly understood, by all who propose practising the healing art. As all the salutary as well as diseased processes which occur in the human body are more or less attended or affected by this action, and as its regulation forms a principal part of the duty of the surgical practitioner, this work cannot be more properly commenced than by treating of its nature, consequences, and management.

      Inflammation may be defined to be, an unnatural or perverted action of the capillary blood vessels of an organ or part of the body, attended with redness, throbbing, swelling, pain, heat, and disorder of function, as well as with more or less disturbance of the system.

      Every part of the body is liable to inflammation; and some writers have divided this action into different kinds, according to the particular tissue which it chiefly involves. But it appears to be always of the same character, though modified by various circumstances, such as the tissue in which it occurs, the state of the constitution, the exciting cause, and the intensity of the action.

      The usual division of the subject, into Acute and Chronic, is that which it is here proposed to adopt. The term Chronic Inflammation is more properly applicable to a consequence of the Acute: but it is at the same time true, that morbid actions proceed more slowly in some constitutions, and in some parts of the body, than in others; and that changes of structure and morbid products, such as generally result from inflammatory action, even occasionally occur, without the prominent symptoms of inflammation being experienced by the patient or detected by the practitioner.

      The term Morbid is used in contradistinction to what is called Healthy Inflammation; but inflammatory action is generally connected, more or less, with a diseased or disordered state of some part of the body. In many circumstances it is highly necessary that a certain degree of incited action of the vessels should occur, and continue for a certain time; as during the uniting of fractures, the adhesion of wounds, and the healing of some sores—and thus far it is healthful: when, however, the action becomes excessive, it must, for this reason, be considered morbid, as it frustrates the natural reparative process; if the action, in fact, proceeds farther than is necessary for reparation, it becomes a disease, and leads to absorption or destruction of parts. In animals possessing the greatest powers of reparation, inflammation, it appears, does not take place at all, or is very slight, and scarcely ever proceeds to suppuration.

      Redness is the first sign of inflammation to be considered; this is observed, in the living body, on the surface, or at the extremities of those canals which terminate externally. The inflamed conjunctiva affords a conspicuous example of this appearance. In a subject that has suffered from an internal inflammatory attack, a good opportunity is frequently afforded of observing the enlarged and injected state of the vessels on which the red colour depends. But inflammation may have existed to a certain degree, and yet the parts may be pale, from the capillaries having emptied themselves into the veins immediately after the patient’s death. The paleness may be also in part caused by the influx of the red globules being impeded immediately after death, or when the patient is