Part 1

ELEMENTS OF SURGERY:

BY

ROBERT LISTON,

SURGEON TO THE NORTH-LONDON HOSPITAL, PROFESSOR Of CLINICAL SURGERY, ETC., ETC., ETC.

FROM THE SECOND LONDON EDITION,

WITH

COPIOUS NOTES AND ADDITIONS,

BY

SAMUEL D. GROSS, M.D.,

PROFESSOR OF SURGERY IN THE LOUISVILLE MEDICAL INSTITUTE, SURGEON TO THE LOUISVILLE MARINE HOSPITAL, ETC., ETC.

Illustrated WITH NUMEROUS ENGRAVINGS.

Philadelphia:

ED. BARRINGTON & GEO. D. HASWELL.

NEW YORK—J. & H.G. LANGLEY: CHARLESTON, S. C.—WM. H. BERRETT: RICHMOND, VA.—SMITH, DRINKER & MORRIS: LOUISVILLE, KY.—JAMES MAXWELL, JR.

1842.

[Entered, according to Act of Congress, in the year 1842, by BARRINGTON & HASWELL, in the Clerk’s office of the District Court for the Eastern District of Pennsylvania.]

TO

WILLARD PARKER, M. D.,

Professor of Surgery in the College of Physicians and Surgeons in the City of New York,

THIS EDITION OF MR. LISTON’S WORK

Is Inscribed,

AS A TESTIMONIAL OF RESPECT

FOR HIS UNTIRING ZEAL IN SURGICAL PURSUITS,

AND OF ESTEEM FOR HIS PRIVATE VIRTUES,

BY HIS FRIEND AND FORMER COLLEAGUE,

THE EDITOR.

PREFACE

TO THE AMERICAN EDITION.

The character of Mr. Liston’s work is too well established to render it necessary for me to say anything in commendation of it. As an outline of surgical science, which is all that can be claimed for it, it is unrivalled in the English language. Written in a bold and graphic style, the distinguished author never hesitates to express his opinion, frankly and fearlessly, of what his judgment and experience have led him to disapprove. In this, as well as in some other particulars, he reminds one forcibly of that great and eccentric surgeon, John Bell. There is no cringing to this man or that, no doubtful or equivocal sentiment, no attempt to theorise or speculate; on the contrary, he comes right out, and clearly tells us what he means. His work, full of vigour and freshness, contains more originality than any other similar publication that has been issued for a long time from the British press. The hand of a master is discernible in every page; and, notwithstanding an occasional incongruity, or _outré_ expression, it is impossible to read it without feeling that it is the production of a great mind, thoroughly acquainted with the subject on which he treats.

Such a work is invaluable to the student; for, independently of imparting sound surgical knowledge, it does more to form his judgment, and to qualify him for the practical duties of his profession than all the compilations in Christendom. Velpeau, with all his learning and all his patience, has never furnished anything equal to it. His "_Medicine Operatoire_" is nothing but a vast storehouse of research, to which pompous doctors may resort for ancient lore, and prosing teachers for materials for instruction. It details with endless minuteness the operative methods of every surgeon, great or little, from the age of Hippocrates to the present period, with their various modifications and improvements, not forgetting the "appreciations" and labours of the able professor himself. Such productions are well enough in their way; they serve to give us an idea of the rise and progress of surgery, and form good books of reference. Beyond this, however, they are of comparatively little utility; the great mass of the profession is no more benefited by them than if they had never been written; few read them, and still fewer understand them. This attempt at erudition pervades, if I mistake not, almost every recent publication on surgery in the French language. Dupuytren is alone free from it. His writings breathe throughout a different and more independent spirit: he speaks like one accustomed to act and to think for himself; and the result is, that he has accomplished more for French surgery than any other Frenchman since the days of Ambrose Paré.

The first edition of the present Treatise was published at Edinburgh in 1831, some time prior to the author’s removal to London. It was originally comprised in three volumes. A second impression, of which this is a reprint, appeared at London in 1840, in a revised and improved form. The favourable reception which the publication has met with in this country, and the desire I have felt to introduce it into the school with which I am connected, as a text-book, have induced me to prepare it for the American press with particular care. Among the additions, properly so called, is an article on Strabismus, and another on Club-foot; two subjects, the former of which was entirely omitted in the English edition, and the latter discussed in a manner altogether incommensurate with the existing state of our knowledge in regard to it. The notes are designed to serve as further illustrations of the text, or to supply deficiencies in relation to certain topics which have been passed lightly over by the author. They might have been extended to almost any number, and it would have afforded me no ordinary gratification, had it been consistent with the views and interests of my publishers, to present what might be considered as a tolerably fair outline of American surgery. For such an object ample materials are extant, highly valuable in themselves, and eminently calculated, when they shall be properly embodied, to reflect credit upon the talents, enterprise, and dexterity of our surgeons.

It need hardly be added, what is self-evident, that the editor of a work is responsible to the public only so far as his own labours are concerned. He adopts only in a general manner, without endorsing all, the views and opinions of his author.

S. D. GROSS.

Louisville Medical Institute, May, 1842.

PREFACE.

The rapid advancement made in the pathology and treatment of surgical diseases demands a perpetual revision and correction of the systematic works devoted to this department of the healing art.

Accordingly, text books, various in merit and extent, have emanated from the different schools. Several of these have, by successive editions, kept pace with the science; whilst others have fallen into disuse.

In this part of Britain, the systems of Latta, B. Bell, and Allan, occupied the field; but it being now vacant, I venture to supply the deficiency, by reducing the heads of my lectures into a compendium, or guide, for those students who resort to this city.

It must appear superfluous to preface such a work by anatomical descriptions, anatomy being now studied more generally, and with greater zeal, than heretofore. Pathology also is more attended to, and better understood. To which circumstances are to be ascribed the improvements in surgical science, as well as in the art of operating.

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.

CONTENTS.

PART FIRST. Page

INFLAMMATION 13 Signs 14 Irritation 20 Termination of Inflammation 25 Adhesion 25 Suppuration 29 Mortification 43 Erysipelas 55 Furunculus and Anthrax 62 Inflammation of Mucous Membranes 65 Serous Membranes 66 Joints 67 Hypertrophy and Atrophy of the Articular Cartilages, with Eburnation 75 Scrofulous Disease of Joints 77 Neuralgic Affections of Joints 78 Growths from the Synovial Membrane and Loose Substances in Joints 79 Affections of Bursæ 80 Coxalgia 81 Alterations of Form in the Head of the Femur 86 Inflammation and Diseases of Bone 94 Suppuration in Bone 96 Caries 96 Necrosis 103 Fragilitas Ossium 110 Mollities Ossium, Rachitis, &c. 110 Arterial System, Affections 116 Aneurism 118 by Anastomosis 127 Inflammation of Veins 130 Tumours 134 Adipose 137 Fibrous 138 Encephaloid 139 Melanoid 142 Carcinomatous 142 Fungus Hæmatodes 147 Painful Tubercle 149 Polypus 150 Encysted Tumours 151 Tumours of Bones 153 Osteosarcoma 154 Spina Ventosa 157 Aneurismal 158 Osseous 158 Hydatic 161 Wounds 164 Tetanus 183 Ulcers 186 Hospital Gangrene 191 Sloughing Phagædena 191 Malignant Pustule 193 Ulcers on the Genital Organs, with their Consequences 195 Scalds and Burns 211

PART SECOND.