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 in-stinctive reliance on the healing power of the tissues, has been common to men everywhere. In both branches of the Aryan 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 and Susruta (commenta-tors of uncertain date on the Yajur-Veda; see SANSKRIT, vol. xxi. p. 294) 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 Intro-duction to his History of Medicine among the Asiatics (London, 1868). The correspondence between the Susruta 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

Operations.

in Susrvrta (such as the rhinoplastic) which were of native invention ; the elaborate and lofty ethical code appears to be of pure Brahmanical origin ; and the very 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 evi-dence 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 Aryan race in a sketch of the rise of surgery, leaving as insoluble the question of the date of the Sanskrit com-pendiums or compilations which pass under the names of two representative persons, Charaka and Susruta (the dates assigned to these ranging as widely as 500 years on each side of the Christian era).
The Suiruta speaks throughout of a single class of practitioners who undertook both surgical and medical cases. Nor were 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 rajah 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 plilebotomists, who were outside the Brahmanical caste.
Susruta 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 has frequently used "this admirable splint," particularly for fractures of the thigh, humerus, radius, and ulna, and it has been subsequently adopted in the English army under the name of the " patent rattan-cane splint."
Fractures were diagnosed, among other signs, by cre-pitus. Dislocations were elaborately classified, and the differential diagnosis given; the treatment was by trac-tion and countertraction, circumduction, and other dexter-ous 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 haemorrhage; 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 some-what noticeably in the ancient surgery of the Hindus ; and the reason of their backwardness in that matter w-as 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. Ob-stetric operations were various, including caesarean section and crushing the foetus.
The medication and constitutional treatment in surgical Medical cases were in keeping with the general care and elaborate- treat-ness of their practice, and with the copiousness of theirment-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 ela-borate and minute directions in the sastras, which were taught by the physician-priests to the young aspirants. Book learning was considered of no use without experience Training and manual skill in operations; the different surgical °f Prac" operations were shown to the student upon wax spread ontltl0ners-a board, on gourds, cucumbers, and other soft fruits; tap-ping 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 vigor-ous period of 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 Chinese, in their knowledge of medicine and surgery, notwithstanding 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"; rheumatism 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. Egyptian. Cupping-vessels made of cow-horn have been found in ancient Egyptian tombs. On monuments and the walls of temples are figures of patients bandaged, or under-going 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. As in the case of the Sanskrit medical writings, the earliest Greek compendiums on surgery bear witness 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 restora-tion 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 a long interval of gradual progress. The surgery of the Hippo-Hippo- erotic Collection (age of Pericles) bears every evidence of cratic finish and elaboration. The two treatises on fractures and surgery. Qn disioc.ations 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 (<pv[w.Ta) 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 ex-cellence 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. Tre-phining was the measure most commonly resorted to, even where there was no compression. Numerous forms of wTounds and injuries of other parts are specified. Ruptures, piles, rectal polypi, fistula in ano, and prolapsus ani were among the other conditions treated. The amputation or excision of tumours does not appear to have been under-taken so freely as in Hindu surgical practice; nor was litho-tomy 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 Alex-school of Alexandria (about 300 B.C.), there is nothing of and.rian surgical progress to dwell upon. The Alexandrian epoch Per,od-stands out prominently by reason of the enthusiastic cultivation of human anatomy—there are allegations also of vivisection—at the hands of Herophilus and Erasistra-tus. The sum and 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) 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, 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 medico, (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 Boman 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-Cato 149 B.C.), who himself practised on his estate according to Major, 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. This eloquent and plausible Greek 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 abandoning themselves to vivisections for the gratification of their curiosity: "Asclepiades capras suas quaerat sine corde balantes et muscas suas abigat sine capite volantes" (De anima, 15). The next figure in the surgical history is Celsus, who Celsus. devotes the 7 th and 8th books of his De re medica exclu-sively to surgery. There is not much in these beyond the precepts of the Bralimanical sastras and the maxims and rules of Greek surgery. Plastic operations for the restora-tion 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 came 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. Guien. Galen's practice of surgery was mostly in the early part of his career (born 130 A.D.), and there is little of special surgical 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 a portion of the sternum for caries and ligature of the temporal artery. It may be assumed that surgical Under practice was in a flourishing condition all through the tne period of the empire from the accounts preserved by empire Oribasius of the great surgeons Antyllus, Leónides, Rufus, and Heliodorus. Antyllus (300) is claimed by Háser 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. Hiiser 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 Leónides and Antyllus removed glandular swellings of the neck (strumse); the latter ligatured vessels before cutting them, and gives directions for avoiding the carotid artery and jugular vein. The well-known operation of Antyllus for aneurism has been mentioned before. Flap-amputations were practised by Leónides 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. Byzan- Whatever progress or decadence surgery may have ex-tine, perienced during the next three centuries is summed up in the authoritative treatise of Paulus of iEgina (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 in his translation and commentary (vol. ii. p. 247).
'' This book (bk. vi.) contains the most complete system of operative surgery which has come down to us from ancient times. . . . Haly Abbas in the 9th book of his Practica copies almost everything from Paulus. Albucasis [Abulcasis] 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 wdiich they supply upon most other surgical subjects is scanty."
It is obviously impossible in a brief space to convey any notion of the comprehensiveness of the surgery of Paulus; his sixth book, with the peculiarly valuable commentary of Adams, brings the whole surgery of the ancient world to a focus ; and it should be referred to at first hand. Paulus himself 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 Arabian, than that of preserving intact the bequest of the ancient world. 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 and Averroes, 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 char-acter 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 Medi-of iEgina there is nothing to record but the names of a few ffival-practitioners at the court and of imitators or compilers. Meanwhile in western Europe (apart from the Saracen civilization) a medical school had gradually 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 Com-pendium Salernitanum, which circulated among the profes-sion. The serious 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 hotel 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 Benedic-tines. 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 classi-cal or Arabian authors: "unus non dicit nisi quod alter." One of the first to go back to independent observation and reflexion was William of Saliceto, who belonged to the school of Bologna; his work (1275) advocates the use of the knife in many cases where the actual cautery was used by ancient prescription. A greater name in the his-tory of mediaeval 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 haemorrhage, and is said to have used the ligature for the former. Contemporary with him in France was Henri de Mondeville of the school of Mont-pellier, whose teaching is best known through that of his more famous pupil Guyde 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 College de St Come. 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 corpora-tion 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, Paracelsus
and Paré, and by the revival of anatomy at the hands of
Vesalius and Fallopius, professors at Padua. Apart from
the mystical form in which much of his teaching was cast,
Para- Paracelsus has great merits as a reformer of surgical
celsus. practice. "The high value of his surgical writings," says
Haser, "has been recognized at all times, even by his
opponents." It is not, however, as an innovator in opera-
tive 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 Heine
Chirurgie (1528) and Die grosse Wund-Arznei (1536-37),—
the latter being the best known of his works. Somewhat
later in date, and of much greater concrete importance
Paré. for surgery than Paracelsus, is Ambroise Paré (1517-
1590). He began life as apprentice to a barber-surgeon
in Paris and as a pupil at the hotel 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 de-
velopments of rational surgery. In 1545 he published at
Paris La methode de traicter les plages /aides par hacque-
butes et aultres bastons a 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 haemorrhage which made am-
putation on a large scale possible for the first time in
history. Like Paracelsus, he writes simply and to the
point in the language of the people, while he is free from
the encumbrance of mystical theories, which detract not a
little 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 me.ans 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.
Six- Surgery in the 16th century recovered much of the
teenth dexterity and resource that had distinguished it in the century. íjg^ perj0rig 0f antiquity, while it underwent the develop-ments 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 Seven-Cartesian philosophies, and the keen interest taken in com- teentu plete systems of medicine, than for a high standard of surgical practice. The teaching of Pare that gunshot wounds were merely contused and not i>oisoned, 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 prac-tised in the best period of Bpman surgery by Leonides and Heliodorus, were reintroduced by Lowdliam, an Oxford surgeon, in 1679, and jirobably used by Wiseman, "who was the first to practise the primary major amputations. Fabriz von Hilclen (1560-1634) introduced a form of tourniquet, made by placing a piece of wood under the bandage en-circling the limb; out of that there grew the block-tourniquet of Morel, first used at the siege of Besangon in 1674; and this, again, was superseded by Jean Louis Petit's screw-tourniquet in 1718. Strangulated hernia, which was for long avoided as a noli me tangere, 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 trans-fusion 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, Quarre and Lasnier. Perhaps the most important figure in the surgical history of the century is Richard Wiseman, the Wise-father of English surgery. Wiseman took the Royalist side man-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, lie joined the Royalist cause in England and was taken prisoner at the battle of Worce-ster. 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 aneurisms by compression, gave an accurate account of fungus articnlorum, and improved the operative procedure for hernia.
The 18th century marks the establishment of surgery Eight-on a broader basis than the skill of individual surgeons of eeutl1 the court and army, and on a more scientific basis than centur-the rule of thumb of the multitude of barber-surgeons and other inferior orders of practitioners. In Paris the Col-lege de St Come gave way to the Academy of Surgery in 1731, with Petit as director, to which was added at a later date the Ecole Pratique de Chirurgie, with Cliopart and Desault among its first professors. The Academy of Surgery set up a very high standard from the first, and exer-cised great exclusiveness in its publications and its hono-rary membership. In London and Edinburgh the develop-ment of surgery proceeded on less academical lines, and with greater scope for individual effort. Private dissecting rooms and anatomical theatres were started, of which per-haps the most notable was Dr William Hunter's school in Great Windmill Street, London, inasmuch as it was the first perch of his more famous brother John Hunter. In Edinburgh, Alexander Monro, 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 Haller, 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 Holtzendorff in 1714, to which was joined in 1726 a school of clinical surgery at the Charité. Mili-tary surgery was the original purpose of the school, which still exists, side by side with the surgical cliniques of the faculty, as the Friedrich Willielm's Institute. In Vienna, in like manner, a school for the training of army surgeons was founded in 1785,—Joseph's Academy or the Joseph-inum.' 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. With-out attempting to enumerate the great names in surgery during the 18th century, it will be possible to introduce the more prominent of them in a brief sketch of the addi-tions to the ideas and resources of surgery in that period. A great part of the advance was in surgical pathology, including Petit's observations on the formation of thrombi in severed vessels, Hunter's account of the reparative pro-cess, Benjamin Bell's classification of ulcers, the observr-tions 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), Hawkins's 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 Pott's treatment of fractures, Gim-bernat's (Barcelona) operation for strangulated femoral hernia, Pott's bistoury for fistula, White's (Manchester) and Park's (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, Bromfield's artery-hook, and Cheselden's operation of iridectomy. Other surgeons of great versatility and general merit were Sharp of London, Gooch of Norwich, Hey of Leeds, David and Le Cat of Bouen, Sabatier, La Faye, Leclran, Louis, Morand, and Percy of Paris, Bertrandi of Turin, Troja of Naples, Palleta of Milan, Schmucker of the Prus-sian army, August Richter of Güttingen, Siebold of Würz-burg, Olof Acrel of Stockholm, and Callisen of Copen-hagen.
Nine-' Two things have given surgical knowledge and skill in teenth the 19th century a character of scientific or positive centurj. cumulativeness and a wide diffusion through all ranks of the profession. The one is the founding of museums of anatomy and surgical pathology by the Hunters, Dupuy-tren, Cloquet, Blumenbach, Barclay, and a great number of more modern anatomists and surgeons ; the other is tho method of clinical teaching, exemplified in its highest form of constant reference to principles by Lawrence and Syme. In surgical procedure the discovery of the an-aesthetic properties of ether, chloroform, methylene, &c, has been of incalculable service; while the conservative principle in operations upon diseased or injured parts and what may be called the hygienic idea (or, more narrowly, the antiseptic principle) in surgical dressings have been equally beneficial. The following are 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 Amussat (1829); the practice of drainage by Cliassaignac (1859); aspiration by Pelletan and recent improvers; the plaster-of-Paris bandage or other immovable applica-tion for simple fractures, club-foot, &c. (an old Eastern practice recommended in Europe about 1814 by the English consul at Bassorah); the re-breaking of badly set fractures ; galvano-caustics and ecraseurs ; the general introduction of resection of joints (Fergusson, Syme, and others); tenotomy by Delpech and Stromeyer (1831); operation for squint by Dieffenbach (1842); successful ligature of the external iliac for aneurism of the femoral by Abernethy (1806); ligature of the subclavian in the third portion by Astley Cooper (1806), and in its first por-tion by Colles; crushing of stone in the bladder by Gruit-huisen of Munich (1819) and Civiale 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 Von Grafe and others; application of the laryngoscope in operations on the larynx by Czermak (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:—Scarpa of Italy (1747-1832); Boyer (1757-1833), 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,"—Boux (1780-1854), Lisfranc (1790-1847), Velpeau (1795-1868), Malgaigne (1806-1865), Nelaton (1807-1873),—all of the French school; of tho British school, John Bell, Charles Bell, Allan Burns, Liston, Wardrop, Astley Cooper, Cline, Travers, Brodie, Stanley, and Guthrie; in the United States, Mott, Gross, and others; in Germany, Kern and Schuh of Vienna, Von Waltlier and Textor of Wiirzburg, Chelius, Hesselbach, and the two Langenbecks. In surgical pathology the discoveries and doctrines of the 19th century are greater in scientific value than those of any antecedent period; and it would be unprofitable to attempt any enumeration of them, or of their authors, in a brief space.
The authorities mostly used have been—Wise, History of Medicine
among the Asiatics, 2 vols., London, 1868 ; Paulus yEgineta, trans-
lated with commentary on the knowledge of the Greeks, Romans,
and Arabians, in medicine and surgery, by Francis Adams, 3 vols.,
London, 1844-47 ; Haser, Gesch. d. Mcdicin, 3d ed., vols. i. and ii.,
1875-81. (C. C.)

PART II.—PRACTICE OE SURGERY.

A great change has taken place in the practice of surgery since the publication (1860) of the article SURGERY in vol. xx. of the 8th edition of the present work. This change is due in great part to the fact that the germ theory of disease has been accepted by the majority of surgical teachers and practitioners. Scientific men have demon-strated that the causation of many diseased conditions is closely connected with the presence in the diseased organ, tissue, or individual of living organisms, which have to a I certain extent been classified, and are supposed to be forms

of plant life. In one sense it is perhaps unfortunate that the article on surgery has to be written at the present time, because, while there are few who now hold that these or-ganisms are inert, there are some who do not grant that they are the cause of disease; and there are many differ-ences of opinion as to the best methods of applying this scientific knowledge to practical use. In other words, although much of the surgical practice of the present day-is founded on a scientific basis, the practical details are still matter of dispute. Improve- It is impossible in the present sketch to go with any merits iii fulness into the details of the experimental research by treat"1 which the truth of the germ theory was proved; but some me'nt. allusion must be made to the salient points which have a bearing on the work of the surgeon. It has long been known that subcutaneous injuries follow, as a rule, a very different course from open wounds ; and the past history of surgery gives evidence that surgeons not only were aware of this great difference but endeavoured, by the use of various dressings, empirically to rjrevent the evils which were matters of common observation during the healing of open wounds. Various means were also adopted to pre-vent the entrance of air, e.g., in the opening of abscesses by the "valvular method" of Abernethy, and by the sub-cutaneous division of tendons in the common deformity termed " club-foot." Balsams, turpentine, and various forms of spirit were the basis of many varieties of dress-ing. These different dressings were frequently cumber-some, difficult of application, and did not attain the object aimed at, while at the same time they retained the dis-charges, and gave rise to other evils which prevented rapid and painless healing. In the beginning of the 19th cen-tury these complicated dressings began to lose favour, and practical 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 amputa-tion on a piece of dry lint, avoiding thereby any unneces-sary movement of the parts. Others left the wound open for some hours after an operation, preventing in this way any accumulation, and brought its edges and surfaces to-gether after all oozing of blood had ceased and after the effusion, the result of injury to the tissues by the instru-ments used in the operation, had to a great extent sub-sided. As a result of these various improvements many wounds healed in a thoroughly satisfactory manner. But in other cases inflammation often occurred, accompanied by pain and suppuration or the formation of pus, and various feverish conditions, due to and in some way connected with the unhealthy state of the wound, were ob-served. These constitutional sequelae frequently proved fatal and the general impression of surgeons was either that the constitution of the patient rendered him liable to these conditions, or that some poison had entered into the wound, and, passing from it into the veins or lymphatic vessels that had been cut across, reached the general circu-lation, contaminating the blood and poisoning the patient. The close clinical association between suppuration (or the formation of pus) in wounds and many of those fatal cases encouraged the belief that the pus cells from the wound entered the circulation (whence the word " pyaemia "). It was also frequently observed that a septic condition of the wound was associated with the 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, and every endeavour was made by surgeons to separate their patients and to improve the ventilation of the larger hospitals. In building hospitals the pavilion and other systems, with windows on both sides and cross ventilation in the wards, were adopted in order to give the patients as much fresh air as was attainable. Hospital buildings were spread over as large an area as possible; the blocks were restricted in height, and if practicable were never higher than two stories. The term "hospitalism" was coined by Sir J. Y. Simpson, who collected statistics com-paring hospital and private practice, by which lie en-deavoured to show that private patients were not so liable to those constitutional sequelae.
This wras very much the condition of affairs when Lister Lister's in 1860, from a study of the experimental researches of &^rm Pasteur into the causes of putrefaction, stated that the alu| ^' evils observed in open wounds were due to the admission treat-into them of organisms which exist in the air, in water, on ment of instruments, on sponges, and on the hands of the surgeon, wounds. These organisms, finding a suitable nidus for their growth and development in the discharges and surrounding tissues, germinate in them and alter their chemical constitution, forming various poisonous compounds, which, if absorbed into the blood, give rise to pyaemia and septicaemia. Having accepted the germ theory of putrefaction, he ap-plied himself to discover the best way of preventing these organisms from reaching the wound from the moment that it was made until it was healed. He had to deal with a plant and he desired to interfere with its growth. This was possible in one of two ways,—either (1) by directly destroying or paralysing the plant itself before it entered the wound or after it had entered, or (2) by an interference with the soil in which it grew, for example, by facilitating the removal of the discharges and preventing their accumu-lation in the wound cavity, and by doing everything to prevent depression of the wounded tissues, because healthy tissues are the best of all germicides. Several substances were then known possessing properties antagonistic to sepsis or putrefaction, and hence called "antiseptic." Act-ing on a suggestion of Lemaire's, Lister chose for his experiments carbolic acid, which he used at first in a crude and impure form. He had many practical difficulties to contend with,—the impurity of the substance, its irritating properties, the difficulty of finding the exact strength in which to use it: on the one hand, he feared to use it too strong, lest it should irritate the tissues to which it was applied and thus prevent healing; on the other hand, he feared to use it too woak, lest its true antiseptic qualities should be insufficient for the main object in view. It is unnecessary to dwell on the details of his tentative ex-periments. As dressings for wounds lie used various chemical substances, which, being mixed with carbolic acid in certain proportions, were intended to give off a quantity of carbolic acid in the form of vapour, so that the wound might be constantly surrounded by an antiseptic vapour 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 his wounds and prevented rapid healing. He began his experiments in Glasgow and con-tinued them after 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 will be best understood by an illustration.
A patient is suffering, let us say, from a diseased con- Ampu-dition of the foot necessitating amputation at the ankle tataon at joint. The part to be operated on is enveloped in a towel joint which has been soaked with a 5 per cent, solution of car-bolic acid. The towel is applied two hours before the operation, with the object of destroying the (putrefactive) organisms present in the skin. The patient is placed on the operating table, and brought under the influence of

chloroform ; the limb is elevated to empty it of blood, and a tourniquet is applied round the limb below the knee. The instruments to be used during the operation have been previously purified by lying for half an hour in a flat porce-lain dish containing carbolic acid (1 to 20). The sponges are lying in a similar carbolic lotion. Towels soaked in the same solution are laid over the table and blankets near the part operated upon. The hands of the operator, as well as those of his assistants, are thoroughly purified by washing them in the same lotion, free use being made of a nail brush for this purpose. The operation is performed under a cloud of carbolized watery vapour (1 in 30) from a steam-spray producer. The visible bleeding points are first ligatured; the tourniquet is removed; and then any vessels that have escaped notice are ligatured. The wound is stitched, a drainage-tube made of red rubber being intro-duced at one corner to prevent accumulation of discharge; a strip of protective (oiled silk coated with carbolized dextrin) is washed in carbolic lotion and applied over the wound. A double ply of carbolic gauze is soaked in the lotion and placed over the protective, overlapping it freely. A dressing consisting of eight layers of dry gauze is placed over all, covering the stump and passing up the leg for about 6 inches. Over that a piece of thin Mackintosh cloth is placed, and the whole arrangement is fixed with a gauze bandage. The Mackintosh cloth prevents the car-bolic acid from escaping and at the same time causes the discharge from the wound to spread through the gauze. The wound itself is protected by the protective from the vapour given off by the carbolic gauze, whilst the sur-rounding parts, being constantly exposed to its activity, are protected from the intrusion of septic contamination ; and these conditions are maintained until sound healing has taken place. Whenever the discharge reaches the edge of the Mackintosh the case requires to be dressed, and a new supply of gauze applied round the stump. The gauze that is used should be freshly made and kept in a tin box to prevent evaporation of the volatile carbolic acid. This precaution is most needful in warm weather. When-ever the wound is exposed the stump is enveloped in a vapour (1 in 30) of carbolic acid by means of the steam-spray producer. At first a syringe was used to keep the surface constantly wet with lotion, then a hand-spray, such as Eichardson's ether-spray producer. More recently a steam-spray producer has been introduced into practice. These dressings are repeated at intervals until the wound is healed, the drainage-tube being gradually shortened and ultimately removed altogether.
In the case of an accidental wound to which the surgeon is called a short time after its occurrence, carbolic lotion (1 to 20) must be injected into the cavity of the wound to destroy any organisms which may have fallen into it. The dressings already described are then applied. In operating on a case in which putrefaction has occurred, every endeavour must be made to destroy the causes of putrefaction which are already present. The substance most frequently used for this purpose is chloride of zinc solution, 40 grains to 1 oz. of water. This powerful anti-septic was extensively used some years ago by Mr De Morgan, Middlesex Hospital, London. When the wound has been thus purified from its septic condition, the after-treatment must follow strictly the plan already recom-mended for a recent wound to avoid secondary contamina-tion at subsequent dressings.
The object Lister had in view from the beginning of his Progress experiments was to place the open wound in a condition since as regards the entrance of organisms as closely analogous Llster-as possible to a truly subcutaneous wound, such as a con-tusion or a simple fracture, in which the unbroken skin acts as a protection to the wounded tissues beneath. The introduction of this practice by Lister effected a complete change in operative surgery. Although the principle on which he founded it was at first denied by many, it is now-very generally acknowledged to be correct. In Germany more especially his views were speedily accepted. In France and England their adoption was slower. In Scot-land, perhaps in consequence of the fact that many saw him at work and worked under him, acquiring perhaps some little part of his persevering enthusiasm, he soon had many believers. Since about 1875 surgeons have been trying to improve and simplify the method; chemists have been at pains to supply carbolic acid in a pure form and to discover new antiseptics, the great object being to get a non-irritating substance which shall at the same time be a powerful germicide. Iodoform, eucalyptus, salicylic acid, boracic acid, corrosive sublimate, have been and are being used, and the question as to their relative superiority is not yet settled. Carbolic acid has the disadvantage of irri-tating the tissues. This is partly counterbalanced by its anaesthetic properties. Absorption of the carbolic acid has occasionally taken place, giving rise to symptoms of poison-ing. But this danger has been greatly lessened by the introduction of pure acid. Of the antiseptics named carbolic acid, eucalyptus, and iodoform are volatile; the rest are non-volatile. At first Lister for some years irrigated a wound with carbolic lotion during the operation, and at the dressings when it was exposed. The introduction of the spray displaced the irrigation method. At the present time the irrigation method is again gaining favour. 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, are entirely 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 do not occur. Alongside of this great improve-ment the immense advantage of free drainage is now uni-versally acknowledged. Surgeons now understand the dangers which lie on every side, and this knowledge causes them to take greater care in the purification and in securing the greater cleanliness of wounds, and some hold that much of the good result follows from these precautions apart from the principle of the system.
Putrefaction has been clearly shown by Pasteur, Tyndall, Putre-and others to be due to the activity of certain lowly forms factive of organized matter. Scientific men have therefore had their pr£au" attention more particularly directed to these lower forms of plant life. A careful study has been made of their life history, and several diseased conditions are now known to be due to the deposit and growth of organisms of a specific form in the blood and in the tissues. This is not the place to discuss points still sub judice; but there can be no doubt, e.g., that the Bacillus anthracis is the cause of splenic fever and of its local manifestation, malignant pustule, and that erysipelas is due to the presence of a micrococcus. There are many other diseases spoken of as zymotic or fermentative, upon which observers are now at work, and hardly a month passes without the publication of new observations (compare SCHIZOMYCETES). It caa

certainly be said that the relation between those organisms and various specific diseases is the question which at pre-sent most occupies the attention both of pathologists and of practitioners of medicine and surgery. It is now known that there are many varieties of organisms (in Crookshank's Bacteriology sixty are described), some of which are hurtful to the human economy, though others are apparently harmless. Those of the former class give rise to an alteration in the tissue in which they grow; and during their growth they alter its composition and cause it to break up into various compounds, some of which, when absorbed into the blood-stream, poison the individual. Some, on the other hand, are either in themselves innocuous or are killed when they enter the blood, which is a fluid tissue and acts as a germicide; hence the tissues in a healthy condition are spoken of as "germicidal." Some appa-rently grow only on dead tissue, or in tissue the vitality of which has been lowered. Ferment- The alteration in the tissue is strictly analogous to a .ations. fermentation—such, for example, as the change which takes place in a solution of grape sugar in which the yeast plant las been planted. The solution breaks up into alcohol and carbonic acid; along with this change there is an increase in the quantity of the yeast. The most common fermenta-tion is the alteration termed "putrefactive" or "septic." The cause of this change is in all probability a special organism named Bacterium termo. It lives on any dead matter containing nitrogen when exposed to heat and moisture; dryness and cold are antagonistic to its growth. Its results are so evident and of such common observation that the term "antiseptic" was used long before the primary cause of the condition was understood. Antiseptics origin-ally were substances which interfered with sepsis. The term has now, however, a wider meaning, and includes any substance opposed to fermentation. " Antifermentative " or " antitheric " would be a better term. An antitheric substance is one which interferes with fermentation by destroying or paralysing the organism which is the primary cause of the condition. The word " antiseptic," on the other hand, should be reserved to denote any substance which is opposed to putrefaction or sepsis,—one form of fermentation. Many of the most dangerous fermentations have nothing in common with putrefaction : the products which result are odourless; the appearances which arise bear no similarity to the changes which occur when putre-factive fermentation is present. Plant the Bacterium lactis in milk, and souring, or the lactic acid fermentation, takes place; plant the Bacterium termo in milk, and putrefactive fermentation occurs. The fermentations of smallpox, vaccinia, syphilis, scarlet fever, typhoid, relapsing fever, typhus, erysipelas, and cholera may be taken as examples of fermentations of the non-putrefactive class. Apparently in them the organism enters the blood-stream, there de-velops and forms its products, which, acting directly or in-directly on the heat-centre, give rise to a specific fever. This fever continues until the soil is worn out, and the organism, finding no longer a nidus for its development, dies out, and recovery takes place. Death of course results if the individual has not sufficient strength to withstand the attack. There is a general law regarding all living things which holds true of these lowly organisms as of the highest: remove its food and the organism dies, or at any rate ceases to develop. It may, however, lie quiescent, again appearing when a new nidus is provided for it. These considerations explain the reason why, after one attack, the individual is protected for a longer or shorter period. They also explain why many diseases are becoming through course of time less virulent than they once were: the soil is becoming exhausted in relation to the special require-ments of the organism, and the organism is therefore incapable of flourishing as it formerly did. Plant the organism in a virgin soil—take, for example, as was un-wittingly done, the organism of measles to Fiji—and a disease which in Great Britain is comparatively harmless becomes a most deadly scourge.
An attempt has been made to divide organisms into two Infective great divisions—the infective and the non-infective. The ™d n,on-first class can grow in living tissue; the second cannot. mfective
OrSTQH-
The first form their products in living matter; the second ;sms. can only grow in dead or lowly vitalized- matter. The in-fective organism can migrate from the original point of en-trance by the vascular and lymphatic streams to distant parts of the body, and may there form secondary foci of infection. As regards the non-infective the manufactory of the poison is principally restricted to the near neighbour-hood of the original point of entrance, generally a wound. It cannot migrate into the living tissues around if they remain healthy. Both kinds of organism form ptomaines (TTTCO/XO, a carcase), the products of the fermentation which result from the breaking up of the tissue or discharge in which the organisms grow. They may enter the blood-stream and poison the patient. Their entry into the blood must be differentiated from the entry of the organism itself into the stream. Clinically, the two conditions, although often met with in one individual, are in many cases distinctly separable. This physiological division of organisms into infective and non-infective is at present only tentative, and much work must be done before a strictly physiologi-cal classification can be attempted; at present the main line of inquiry must be principally morphological. Even in this direction a difficulty meets the observer, because organisms change their shape according to the media in which they are cultivated.
In the present article only a general view of the present aspects of surgical practice can be given. Special stress will be laid upon the principles which guide the surgeon in his daily work. For full particulars with reference to any special points the reader is referred to Holmes's System of Surgery, Erichsen's Science and Art of Surgery, and Gross's System of Surgery.
Surgical affections may be divided into two great classes, —those which are the result (1) of injury and (2) of disease.

I. INJURIES.

Before proceeding to the consideration of the different injuries Shock, it will be necessary to say a few words about the general condition termed shock or collapse, which supervenes after a severe injury. Care must be taken not to confound this state with faintness or syncope from loss of blood. Undoubtedly in many cases both con-ditions are present. Syncope from loss of blood is considered below. Syncope from mental emotion differs from shock in degree only. In shock the patient is pale, and bathed in cold clammy perspiration; his sensibility is blunted ; his pulse is small and feeble ; he is unable to make any active exertion, but lies in bed indifferent to external circumstances, and can only be roused with difficulty ; he frequently complains of a feeling of cold ; and he may have a distinct shivering or rigor. These symptoms may continue for some hours ; the first evidence of improvement is that he shifts his position in bed and complains of the pain of the injury which has caused the condition. The pulse becomes stronger, and he then passes from the state of shock into the condition of reaction. If the improvement continues recovery will take place, but if it is only transient the patient will sink back again into a drowsy condition, which, if it persists, will end in death. In severe cases there may be no reaction ; the patient then gradually becomes weaker and weaker, his pulse feebler and feebler, till death ensues. Shock is due to an impression conveyed to the central nervous system by an afferent nerve of common or special sensation. This impression produces a change in the medulla oblongata, by which the nerve-centres are so affected that a partial paralysis or paresis of the voluntary and involuntary muscular fibres in the body takes place. In consequence of the change in the voluntary muscles the patient is unable to lift his arm or move his leg; the respiratory functions are performed wearily, and the

muscle of the heart contracts feebly ; the muscular fibres in the
walls of the blood-vessels lose their tonicity and the blood-vessels
dilate ; the blood collects in the large venous trunks, more especi-
ally of the abdomen ; the vessels of the skin are emptied of blood,
giving rise to the marked pallor. Two of the great causes that
keep up the normal circulation of the blood through the body are
in partial abeyance : the heart has not sufficient energy to contract,
and there is not a sufficient quantity of blood passing into it from
the blood-vessels. The heart beats feebly (1) because its nervous
energy is lowered, and (2) because it has not a sufficient quantity
of blood to act upon. An understanding of these facts gives the
general indications for treatment,—(1) external stimulation over
the heart by mustard poultices or turpentine stupes ; (2) elevation
j>f the limbs, to cause the blood to gravitate towards the heart;
(3) manual pressure on the abdominal cavity from below upwards,
to encourage the flow of blood from the dilated abdominal veins
into the heart. These different measures may be supplemented
by the administration of stimulants by the mouth, or, if the patient
cannot swallow, by subcutaneous injection of a diffusible stimulant,
Syncope, such as ether or ammonia. In syncope or faintness from mental
emotion the weakened heart cannot drive a sufficient quantity of
blood to the brain ; the patient feels dizzy and faint and falls down
insensible. The condition is a transitory one, and the recumbent
posture, assisted if need be by elevation of the limbs, causes the
blood to gravitate to the heart, which is thereby stimulated to
contraction ; a sufficient quantity of blood is then driven onwards
to the brain, and the insensibility passes off. If the patient is in
the sitting posture when he feels faint, the head should be depressed
between the knees, which will cause the blood to rush to the brain,
and the faintness will pass off.
Harnior- With few exceptions the soft parts are freely supplied with blood-
rhage. vessels, and as a preliminary to a consideration of the different
forms of injuries it will bo well to say a few words about haemorrhage
or bleeding. If a blood-vessel is torn or cut across, the blood within
it escapes, either externally on to the clothes or floor, or, in the
case of a subcutaneous injury, into the tissues, giving rise to
ecchymosis. Cessation of the bleeding may take place in conse-
quence of an arrest of the hemorrhage either by nature's effort or
by the adoption of artificial means by the surgeon. The loss of
blood may be so great that the heart's propelling power is weakened,
and in this way the natural arrest is assisted. But there is always
a danger that with the arrest of the haemorrhage the heart's action
may recover its power and the bleeding recommence. In arresting
hemorrhage temporarily the chief thing is to press directly on the
bleeding part. The pressure to be effectual need not be severe, but
must be accurately applied. If the bleeding point cannot be reached,
the pressure should be applied to the main artery between the
bleeding point and the heart. In small blood-vessels pressure will
be sufficient to arrest haemorrhage permanently. In large vessels
it is usual to pass a ligature round the vessel and tie it with a reef
knot. Apply the ligature also, if possible, at the bleeding point,
tying both ends of the cut vessel. If this cannot be done, the
main artery of the limb must be exposed by dissection at the most
accessible point between the wound and the heart, and there liga-
tured. Haemorrhage has been classified in three varieties—(1)
primary, occurring at the time of the injury ; (2) reactionary, or
within twelve hours of the accident, during the stage of reaction ;
(3) secondary, occurring at a later period, and caused by unhealthy
processes attacking the wound and giving rise to ulceration of the
coats of the blood-vessels. In treating these different varieties the
principles already laid down hold good. In cases of severe haemor-
rhage the patient suffers from syncope owing to loss of blood.
Syncope from loss of blood is to be treated on the same principles
as those already laid down for shock. But in addition it may be
necessary in cases of severe haemorrhage, in which much blood has
been lost, to introduce into the circulation fluid which will give
the heart something to act upon. Blood drawn directly from the
arm of a healthy person, and introduced through an opening in the
vein of the arm, has frequently been made use of. The tendency of
the blood to coagulate when brought in contact with foreign matter
has led to the adoption of ingenious instruments to avoid this
danger. Some surgeons have used defibrinated blood, and others
milk. The opinion is at present gaining ground that a nutrient
fluid is unnecessary, and that all that is required is to introduce an
aseptic neutral fluid at the temperature of the body which has no
tendency to cause coagulation of the blood with which it mixes. A
saline solution, composed of '75 per cent, of common salt in dis
tilled water, fulfils all these requirements; 4 to 6 oz. are generally
sufficient. Becent experiments have been made by which blood
drawn from the arm of the giver is mixed with a solution of phos
phate of soda. This admixture prevents the blood from coagulat-
ing, and it can be introduced into the blood-stream with safety.
Con- In a recent contusion careful pressure should be applied, with
tusions. cotton wadding fixed in position with a bandage. The aim is to prevent ecchymosis and to hasten the absorption of the effused blood after it has escaped into the tissues. Accurate pressure fulfils these ends more perfectly than the commoner application of cold.
The procedure for the treatment of an open wound is—(1) arrest Wound of haemorrhage ; (2) removal of any foreign bodies in the wound ; treat-(3) careful apposition of its edges and surfaces,—the edges being best ment. brought in contact by the use of horse-hair stitches, the surfaces by carefully applied pressure ; (4) free drainage of the wound to prevent accumulation either of blood or of serous effusion, which may bo done—(a) by leaving the dependent corner open, or (b) by introducing a drainage-tube, a skein of catgut, or a skein of horse-hair ; (5) avoidance of putrefaction by the use of antiseptic pre-cautions ; (6) perfect rest of the part by appropriate means during the cure. These methods of treatment require to be modified for wounds in special situations and for those in which there is much contusion and laceration. In punctured wounds free drainage is of primary importance. AVhen a special poison lias entered the Poisoned wound at the time of its infliction or at some subsequent date the wounds, following dangers have to be combated—(1) an intense inflamma-tion in the wound itself and surrounding parts ; (2) inflammation of the lymphatic vessek leading from it; (3) inflammation of the lymphatic glands ; (4) blood-poisoning of the general circulation. One of the commonest poisons is that connected with wound putrefaction ; of others some are the result of diseased action in the lower animals, e.g., hydrophobia, whilst some are special diseases in man. These diseased conditions are at the present time being carefully, studied, and the observations all tend to one conclusion, that they are due to specific organisms which have found entrance into the diseased animal or man, and, finding there a suitable nidus for their growth and development, have set up a specific disease. If the surgeon is accidentally wounded in operating on the living subject, or the pathologist in making a post-mortem examination, the poison may pass into the wound and give rise to one or more of the symptoms already indicated. There can be no doubt that these special poisons,1 which are spoken of as pathogenic or infect-ive, are in some way associated with low forms of plant life, and that in this they resemble the poison of putrefaction. If the operator is in good health the poison will generally have little effect; if he is in bad health the effect may be very severe. We do not yet know in wdiat cases bad results are to be expected. The great point in every doubtful case is to purify the wound thoroughly with some powerful antiseptic, so as to destroy the poison at the point of inoculation. If the poison escapes the germicidal action of the antiseptic used and enters the system, the patient should be stimu-lated, as the poison exercises a depressing action. For hydrophobia no cure is at present known. Experiments are, however, now (1S87) being made by Pasteur which will throw some light on this dreadful disease.
Burns are dangerous accidents in young children and in old people Burns, when the areas affected are large, and when they are situated over the cavities of the body. The patient may die of shock soon after the accident, of deep-seated inflammations coming on duringthe stage of reaction, or of hectic, which in all probability is a form of chronic pyemia associated witli profuse discharge from the wounded surface. To prevent death from any of these causes stimulating treatment is necessary. It has long been known that it is important to keep the air from the wounded surface, and antiseptic dressings must be used to prevent the access of organisms to it. When the skin is destroyed to any great extent contraction is apt to take place, followed by deformity. Care must be taken during the process of cure to prevent this, by keeping the limb in an extended position during the treatment of burns on the flexor surface. To hasten cicatrization after a burn in which the skin has been destroyed grafts of epidermic tissue may be planted on the granulating surface according to the method of Beverdin. These grafts, each the size of a pin's head, become fixed and from them cicatrization spreads over the surface. After cicatrization the tendency to contraction is not nearly so great. Epidermis grafting must not be confounded with skin grafting, in which the grafts are of the whole thickness of the skin.
A bone may be broken at the part where it is struck, or it may Fracture, break in consequence of a strain applied to it. In the former case the fracture is generally transverse and in the latter more or less oblique in direction. The fully developed bone is broken fairly across ; the soft bones of young people may simply be bent—"green stick" or "willow" fracture. Iractures are either simple or com-pound. A simple fracture is analogous to the contusion or sub-cutaneous laceration in the soft parts ; a compound fracture is analogous to the open wound in the soft parts. The wound of the soft parts in the compound fracture may be caused either by the same force which has caused the fracture, as in the case of a cart wheel going over a limb, first wounding the soft parts and then fracturing the bone, or by the sharp point of the fractured bone coming through the skin. In either case there is a communication between the external air and the injured bone. As some years elapse before the epiphyseal extremities of the bone become united by osseous deposit to the shaft, external violence may cause a separation of the epiphysis from the shaft. This variety of fracture is termed a diastasis. When a hone is broken there is generally distortion and preternatural mobility, inability to use the limb, and pain on pressure over the fractured part. In the majority of fractures there is also crepitus,—the feeling elicited when two osseous surfaces are rubbed together. When a bone is bent, or when a diastasis has occurred, there is no crepitus. It is also absent in impacted fractures, in which the broken extremities are driven into one another. In order to get firm osseous union in
a case of fracture the great points to attend to are accurate ap-
position of the fragments and complete rest of the broken bone.
Accurate apposition is termed " setting the fracture " ; this is best
done by the extension of the limb and coaptation of the broken
surfaces. Complete rest is attained by the use of appropriate
splints. As a rule ft is of great importance to command the joint
above and below the seat of fracture. In cases of fracture near a
joint, in which very commonly a splintering of the bone into the
joint has taken place, more especially in those cases in which
numerous tendons in their tendinous sheaths have been stretched,
if the surgeon forgets that there may be effusion into the joint and
the tendinous sheaths, and that this effusion may form fibrous
tissue leading to stiffness of the joint and stiffening of the tendons,
the result, more especially in old people, will be a permanently stiff
joint or permanently stiffened tendons. Care must be taken in
such instances by gentle passive movement during the process of
cure to keep the joint and tendons free from the fibrous formation.
To take a common example,—in fracture of the radius close to the
wrist joint, it is necessary to apply appropriate splints to keep the
bone at rest, and to arrange them so that the patient can move his
fingers and thumb to prevent stiffness, and the splints must be
taken off occasionally in order to move the wrist joint gently. If,
however, the splints extend to the points of the fingers and are
kept on for some weeks without removal, the consequence is a
normal radius and a useless hand. Instances occasionally occur
iu which non-union results, either from want of formative power
on the part of the individual or in consequence of improper treat-
ment by the surgeon. For the treatment of this condition the
reader is referred to one of the systematic works mentioned above.
For fractures of the cranium see below, p. 688.
Treat- There is no form of injury in which the truth of the principles
ment of first advocated by Lister has been more prominently brought
com- forward than in compound fractures. When such an accident
pound occurs from direct violence the soft parts are generally much
fractures, crushed and the bone is frequently comminuted. When a bone is
broken from indirect violence the fracture is frequently oblique
and the sharp point of the bone projects through the skin. In
such a case the injury is, as a rule, not so severe. Formerly com-
pound fractures were the dread of the surgeon : septic inflammation
occurring in the wound reached the open medullary cavity of the
bone, and the open blood-vessels of the bone gave easy access to
the causes and products of the inflammation into the general blood-
stream, giving rise to pyaemia. It is not asserted, however, that
this accident always occurred. In a case of compound fracture the
wound should be at once covered with a towel thoroughly soaked
in a five per cent, solution of pure carbolic acid. And, if some time
elapses before the arrival of a surgeon, more of the solution must
be poured upon the towel, which should be kept thoroughly soaked.
After the fracture is set it will probably be necessary to inject the
solution into the interstices of the wound, over which an efficient
antiseptic dressing must be applied. When the injury is so severe
that it is impossible to preserve the limb, amputation is the only
resource. It is often a difficult thing to say when the surgeon
should amputate. The question will frequently be settled by a
consideration of the general circumstances and surroundings of the
patient, and no definite rules can be laid down. Speaking in general
terms, an artificial substitute may take the place of the lower limb,
but no artificial substitute can ever efficiently take the place of the
upper limb ; and therefore surgeons will run some risk in attempt-
ing to save an upper limb which they will not do in treating an
injury of a lower limb.
i oint There are three principal types of joint injury—(1) sprain or strain,
injury. in which the ligamentous and tendinous structures around the joint are stretched and even lacerated ; (2) contusion, in wdiich the cartilaginous surfaces of the opposing bones in the joint are driven forcibly together ; (3) dislocation, in which the articular surfaces are separated from one another ; in this last injury the ligamentous capsule of the joint must be torn to allow the accident to occur. Joint strength may be classified anatomically under three heads—
(1) ligamentous, due to the ligaments binding the bones together ;
(2) osseous, due to the shape of the bones forming the joint; (3) muscular, due to the muscles surrounding the joint. Ligamentous strength predisposes to sprains, osseous to contusions, and muscular to dislocations. A joint is frequently saved from injury in consequence of the relative weakness of a bone near it. The ankle joint is saved by the weakness of the fibula, the wrist joint by the weak-ness of the radius, the sterno-clavicular joint by the weakness of the clavicle; the fracture of the bone preserves the joint from injury. The tonicity of the muscular structures around a joint often prevents a dislocation, the patient being prepared for the violence to which his joint is subjected. The osseous strength of a joint will depend very much on the position of the limb at the time of the accident.
When a joint is sprained or contused there is effusion into it and into the structures around it. In such cases accurately applied pressure will prevent effusion, and along with gentle passive exer-cise and rubbing will prevent subsequent stiffness. When a joint is dislocated it is of importance to restore the hones to their normal position as soon as possible after the accident. WTithin the last few years, in several dislocations, the treatment by extension of the limb and forcible pressure of the bones back into their normal position has been given up, and a method of treatment at one time in use in the French schools has been revived by Dr Bigelow of Boston, Mass., who has pointed out that with less force and there-fore less injury a dislocated joint may be reduced by manipulation. The great principle at the root of this treatment is to manipulate the limb so as to cause the dislocated bone to pass back into its normal position by the same path by which it left it. In com-pound dislocations the same precautions must be attended to as in compound fractures.

II. PROCESS OF REPAIR.

After an injury certain changes take place, which, if kept within bounds, terminate in repair, in other words, in a restoration of the injured part to a condition as nearly as possible normal. When the injury is severe the restoration may fall far short of the normal. The recovery may take place with very little pain or discomfort even in severe injuries. Frequently, however, as the result either of improper treatment on the part of the surgeon or of feebleness on the part of the person injured, local uneasiness and a general feverish condition arise, wdiich interfere with the healing. When these evil results follow, a local death of tissue in a greater or less degree is observed. Three forms of local death have been described Forms of —(1) suppuration or the formation of pus ; (2) ulceration, or the local formation of an ulcer ; (3) mortification, or the formation of a death, slough. These three processes run imperceptibly into one another. They are not distinctly separable from one another, and they very frequently occur together. It is to be noted that the process of repair and the local death which interferes with a painless repair differ only in degree. As a general rule, in the truly subcutaneous wound of tissue, be it the soft parts or bone, the changes that take place ending in its repair are simple and uncomplicated ; it is in the open wounds of the soft parts and in compound fractures of bone that complications arise.
In order to understand this process, it will be best to take a Repair simple injury, such as a clean cut. As the result of the passage of of an even the sharpest knife through the tissues a microscopic laceration incised along the line of the incision must occur. The skin, subcutaneous wound, fat, fascia, and muscle are divided. These parts being vascular, bleeding takes place from the cut vessels. Let us suppose that the bleeding has ceased, and that the surfaces and edges of the wound are not brought into contact. The retractile power of the tissues, when they are divided, necessarily produces a trench-shaped gap. If the sides of this gap are watched a weeping of a straw-coloured fluid will be observed, which, when examined under the microscope, is seen to have corpuscles floating in it. The fluid is the liquor sanguinis of the blood, and the corpuscles are the blood corpuscles. In the blood as it circulates throughout the vessels in the body, the yellow or red blood corpuscles are greatly in excess of the white. In this fluid the white blood corpuscles are very numerous. Careful observation, with the aid of a sufficiently powerful micro-scope, will show the formation of fine fibrils of a solid substance, which gradually extend over the field; this fibrillation takes its start from the white blood corpuscles. The effusion has coagulated. A soft solid—fibrin—is formed, which gradually contracts, and a clear fluid escapes; this is the blood serum. To return to the wound,—in consequence of the injury the smaller blood-vessels dilate, their walls are thinned, and a stasis or stoppage of the flow of blood within these vessels takes place. The stasis is caused by the injury to the vessel walls, rendering the blood corpuscles more ad-hesive. The circulation is going on in the vessels beyond the area of stasis. The blood in a state of stasis acts as an obstruction, and con-sequently there is an increased pressure on the inner surface of the thin walls. As a result the fluid part of the blood or liquor sanguinis and the corpuscular elements of the blood escape into the tissues and on to the surface of the wound. On this surface and in the tissue next the surface a clotting takes place, and fibrin is formed. The surface of tho wound becomes glazed, and as the fibrin contracts the blood serum oozes out upon the wound surface and escapes. The glazed surface then becomes vascular; new blood-vessels are formed in it; and through these a circulation is set up continuous with the circulation in the blood-vessels around. If the surfaces of the gap are now brought into gentle contact, the blood-vessels on the two surfaces will unite. At first the uniting tissue is very succu-lent and vascular, and further changes must occur before the uniting

medium is consolidated. This is effected by the formation of fibrous tissue in the deeper parts of the uniting medium and by the forma-tion of epithelial tissue in the more superficial parts where the skin is divided. Along with these changes the uniting medium becomes less vascular, and a linear scar is the result.
This is the case of an incised wound in which the surfaces are not brought at once into contact. If, however, this is done, the same changes take place, and in a small wound no untoward results need follow. But in a wound of some size there is danger in bring-ing the edges of the wound into contact. In consequence of the difference in the retractile power of the different tissues that are divided, it may be impossible to bring the deeper parts into accurate contact. The patient will complain of local pain, accompanied by a throbbing sensation, showing that an accumulation of serum has taken place. If a stitch is removed, the serum will escape and the local uneasiness disappear. If, however, no relief is given, the re-tained serum, pressing upon the surrounding tissues and acting as a foreign body, will cause effusion of more serum. The white blood corpuscles will pass from the vessels in large numbers, will die, and practically a cemetery of white blood corpuscles will be formed ; if a stitch is then removed a creamy fluid escapes. This fluid is termed "pus." Once the tension is relieved, the local uneasiness disappears ; but the wound cannot then heal by primary union. The walls of the cavity must again become glazed ; vascularization must take place ; and, as the walls of the cavity gradually come together by contraction, fibrous tissue is formed. This is union by second intention.
Abscess The collection of white blood corpuscles floating in the effusion and pus and eventually forming pus is termed an abscess. Pus may also form forma- amongst the tissues after a blow or other injury. As the result of a tion. blow a certain area of tissue becomes congested, and effusion takes place into the tissues outside the vessels ; the effusion coagulates and a hard brawny mass is formed. This mass softens towards the centre; and if nothing is done the softened area gradually increases in size, the skin becomes thinned over it, the thinned skin loses its vitality, and a small slough is formed. When the slough gives way, the pus escapes. Such shortly is the history of an acute abscess under the skin, and the explanation generally given is that a local necrosis or death of tissue takes place at that part of the inflammatory swelling farthest from the normal circu-lation. When the dying process is very acute death of the tissue occurs en masse, as in the core of a boil or in the slough in a carbuncle. Sometimes, however, no such evident mass of dead tissue is to be observed, and all that escapes when the skin gives way is the creamy pus. In the latter case the tissue has broken down in a molecular form ; in the former case it has broken down en masse. After the escape of the core or slough along with a certain amount of pus, a cavity is left, the walls of which become lined with lymph. The lymph becomes vascular, and receives the name of granulation tissue. The cavity heals by second intention. Pus may accumulate in a normal cavity, such as a joint or bursa. It may also be met with in the cranial, thoracic, and abdominal cavities. In all these situations, if the diagnosis is clear, the principle of treatment is free evacuation of the pus, and in joints and in the peritoneal and pleural sacs washing out the cavity at the time of opening, free drainage, and careful antiseptic treatment during the subsidence of the inflammatory process. The tension is relieved by letting out the pus. If the after-drainage of the cavity is thorough the formation of pus ceases, and the serous discharge from the inner side of the abscess wall gradually subsides ; and as the cavity contracts the discharge becomes less and less, until at last the drainage-tube can be removed and the external wound allowed to heal. The large collections of pus which form in connexion wdth disease of the vertebrae in the cervical, dorsal, and lumbar regions are also now treated by free evacuation of the pus, with careful antiseptic measures. In all cases care should be taken to make the opening as dependent as possible in order that the drain-age may be thoroughly efficient. If tension occurs after opening by the blocking of the tube, or by its imperfect position, or by its being too short, there will be a renewed formation of pus. TJlcera- When a considerable portion of tissue dies in consequence of an tion. *' injury, the death taking place by gradual breaking down or dis-integration, the process is termed ulceration, and the result is an idcer. As long as the original cause which formed the ulcer is at work, the gap in the tissues becomes larger and larger. Suppose that the ulcerative process is going on and the ulcer is spreading. The ulcer is then painful and the parts around are inflamed. Remove the cause by appropriate treatment and the necrotic process ceases, the shreds of tissue are cast off, the ulcer gradually cleans, the inflammation subsides, the pain disappears : the ulcer becomes a healing ulcer. The surface of the gap becomes glazed, and those changes take place in it which have already been described as occurring in an open wound. The gap gradually contracts in size. Round the edges cicatrization occurs, leaving a scar or cicatrix. Within the last few years the process of cicatrization has been hastened by planting on the granulation tissue small grafts of .epidermic tissue in the maimer already described (p. 681). There can be little doubt that the growth of an ulcer, as well as the disintegrating process which precedes its formation, is closely associated with the multiplication of low forms of plant life in the decaying tissue. By destroying these organisms with some powerful antiseptic the destructive process may be checked. Since these organisms live on decaying matter, they are termed "sapro-phytic." The healthy tissues are antagonistic to their growth, and any treatment which renders the tissues around the gap healthy will interfere with their further development. The entrance of those organisms into a wound made by the surgeon, if they find in it a suitable soil for their development, is undoubtedly also a fertile cause of suppuration in wounds. But it must be distinctly remem-bered that any means which are adopted to keep the injured tissues in a healthy condition interferes with the growth of these sapro-phytes as directly as if the surgeon used some antiseptic substance which destroyed them. What relation obtains between a local necrotic process, such as the formation of a boil with its central slough, situated necessarily in the first instance under the skin, or the equally necrotic process, the formation of pus in a subcutaneous abscess, and these low forms of plant life ? There can be no doubt that by the injection into the tissues of a powerful irritant these necrotic changes can be induced without the intervention of organisms. Brofessor Ogston and Mr Watson Cheyne have also shown that micrococci are present in the great majority of acute subcutaneous necrotic inflammations, as they are commonly met with in the human body. Here the question at present rests. The opinion of the present writer is that in all probability they are the cause of the necrotic process. It is not asserted that they are the cause of the primary inflammation, which need not go on to necrosis : but the probability is that they find in the inflamed area a nidus for their growth and development. It is not known how they cause it, whether by direct action upon the tissues or by irritating products formed during their growth. The organisms described by Ogston and Cheyne have a life history and require conditions for their existence and development different from those demanded by the saprophytic organisms already described. To . reach the subcutaneous area of inflammation they must pass by the blood-stream, and must be able to exist in the living blood. They are probably associated with the infective class of organisms. In some suppurations at the present moment, such as acute suppurative periostitis, the formation of pus under the periosteum connected with bone, a suppuration within the medullary cavity of a bone called osteomyelitis, and in acute ulcerative endocarditis, the organ-isms met with are undoubtedly infective. We do not know exactly how they enter the blood-stream, but we know that they can live in it, and that the occurrence of these diseased conditions is un-doubtedly a local effect closely connected with blood-poisoning.
A portion of the body may die in consequence either of an intense Mortifi-inflammation or of a cutting off of the blood-supply. Besides these cation or two distinct varieties there is a great intermediate group of cases in gangrene, which both causes may be at work. A comparatively slight injury affecting a portion of the body imperfectly supplied with blood may give rise to an inflammatory condition which in a healthy part would be easily checked, but which in consequence of imperfect nutrition may end in mortification. Whilst the pressure of a tight boot in an old person with atheromatous vessels can give rise to mortification, the same pressure in a healthy person would give rise only to an evanescent redness. Frost-bite is a localized death of a portion of the body which has been exposed to prolonged cold. It may attack the fingers or toes. The death may occur directly without any intermediate reactionary inflammation, or it may follow an excessive reaction. The rule of treatment in all cases of gangrene in which there is a tendency to death is to keep the part warm by layers of wadding, but to avoid all methods which hurry the returning circulation; because any such increase would be followed by excessive reaction, which in its turn in a part already weakened would be followed by secondary death. When the part is dead, envelop it in antiseptic wadding to prevent putrefaction ; wait until the line of demarcation between the living tissues and the dead part is evident, and then, if the case permits, amputate at a higher level. In spreading gangrene in which sepsis is present, and in which no line of demarcation forms, the best chance for the patient—at best a poor one—is to amputate high up in sound tissues. In these cases the blood is generally poisoned, and if the patient recovers from the primary shock of the operation a return of the decaying process may attack the stump, and carry him off.
III. DISEASES. 1. Diseases of Blood-vessels. An aneurism, in so far as we have to deal with it at present, may Aneur-be defined as a sac communicating with the lumen of an artery, ism. The sac-wall may be formed of one or more of the arterial coats which have become dilated. The tissues around, being condensed and being more or less adherent to the sac-wall, strengthen and support it. The dilatation of the arterial coats is generally due to a local weakness, the result of disease. The diseased condition is almost always a chronic form of inflammation, to which the name atheroma,

is given. In some instances the local* weakness may he due to an injury bruising or lacerating the vessel and injuring its internal coat. When an artery is wounded and when the wound in the skin and superficial structures heals, the blood may escape into the tissues. In this case it displaces the tissues and by its pressure causes them to condense and form the sac-wall. The coats of the vessels, more especially when they are diseased, may be torn from a severe strain, and the blood will then escape into the condensed tissues forming the sac-wall. When one or more of the vessel coats form the sac there results what is called a true aneurism ; in those in-stances in which the sac-wall is formed by the condensed tissues around we have a primary false aneurism ; when a true aneurism bursts and the blood escapes into the tissues around it, as sometimes occurs in deep-seated aneurisms, giving rise to secondary localized accumulation, the term secondary false aneurism is used. In both varieties of false aneurism the swelling is more diffuse and the pulsation as a rule is less marked than in the true aneurism.
The blood in an aneurism is at first in a fluid state, and at each beat of the heart a certain amount passes into the sac, causing its ex-pansion. In all aneurisms there is a tendency to coagulation of the Wood, and a blood-clot is deposited in a laminar form on the inner surface of the aneurismal sac. In some instances this laminar coagulation by constant additions gradually fills the aneurismal cavity. The pulsation in the sac then ceases ; contraction of the sac and its contents gradually takes place ; the aneurism is cured. On the other hand, if the blood within the sac remains fluid, the aneurism will gradually increase in size ; the tissues over the aneurism and the sac-wall will become thinned, and at last give way ; and death occurs from haemorrhage. Treat- In the treatment of true aneurism the great principle is to encour-ment of age coagulation in the aneurismal sac. This can be done by lessening true the force of the circulation generally or locally. The general force aneur- of the circulation can be lessened by low diet, rest in bed, avoid-ism. ance of all causes of vascular excitement, and by the administration of large doses of iodide of potassium. The force of the circulation can be decreased locally and temporarily by the application of a ligature to the artery between the aneurism and the heart or by the application of pressure upon the main vessel at a convenient point between the aneurism and the heart. The general treatment is available in all cases. The local treatment by operation or by compression is only available in those instances in which the aneurism is so situated that the blood-vessel can be compressed or ligatured, as in aneurisms of the head and neck or of the extre-mities. In certain aneurisms in the lower part of the neck and upper part of the thorax, in which a ligature cannot be applied between the aneurism and the heart, the blood-flow through the aneurismal sac has been diminished by the application of a ligature to one or more of the main vessels on the distal side of the aneur-ism. The blood-supply to the parts beyond the aneurism being thus cut off, the immediate effect is increased pressure on the aneur-ismal sac ; but, since the parts accommodate themselves to altered circumstances, as the collateral blood-vessels increase in size, be-coming the main vessels of supply to the parts beyond, the original channel becomes of secondary importance, the result being a diminu-tion in the size of the main vessel and diminished blood in the sac, encouraging coagulation and contraction of the aneurismal sac. Practically the same effect has sometimes been obtained in a per-manent way, as in cases of rapidly increasing aneurism of the sub-clavian artery in the root of the neck by amputation of the upper extremity at the shoulder joint. And within the last few years, in popliteal aneurism, the same thing has been done temporarily by the application of an elastic bandage to the limb from the foot upwards to the popliteal space, emptying the blood-vessels below the knee, and in this way cutting off the blood-supply tempo-rarily. The application of the elastic bandage is continued up the thigh, care being taken not to make firm pressure with the bandage as it passes over the aneurism behind the knee joint, so that the sac may not be emptied of blood. If the sac were emptied, the object in view would be defeated, because there -would be no blood in the sac to coagulate. The continuation of the bandage in the thigh above the aneurism is practically a compressing agent applied to the artery on the proximal side of the aneurism. The rationale of this treatment of popliteal aneurism, due to Dr Walter Reid of the British navy, may, if this explanation is correct, be said to owe its success to the fact that in it we combine the two great principles which check the blood-pressure locally, i.e., a cutting off of the blood-supply beyond the aneurismal sac and compression on the main vessel on the proximal side. It is to be noted that all these different moans of checking the blood-pressure within the aneurismal sac are temporary in their action. The temporary arrest by compression, the equally temporary arrest by the application of a ligature, in the latter case the collateral anastomosing circulation taking the place of that of the main trunk which has been ligatured, start the process of coagulation within the sac, and, the process being once started, complete consolidation gradually takes place. Although these methods of treatment are principally of value in true aneurism, they are also to a certain extent useful in secondary false aneurism. In primary false aneurisms, on the other hand, we have to deal with a wounded vessel in which the blood, instead of being poured out externally, is poured into the tissues, and is practically a (chronic) bleeding point; the principle of treatment is to open the sac, turn out the clots, and ligature the artery above and below the bleeding point.
The veins are liable to inflammation (phlebitis). When this occurs Diseases the blood in the vein is liable to coagulation, forming a clot or of veins, thrombus, which, if displaced from its original position, either makes its way as an embolus towards the heart and is there arrested, or passes through the cavities of the heart into the lungs, there sticking and giving rise to lung symptoms. If the thrombus is formed in the hemorrhoidal plexus, it passes as an embolus by the portal system into the liver. If it is formed in the left side of the heart, it may pass into the large vessels at the root of the neck and reach the brain, giving rise to symptoms of brain disease. The thrombus may be formed apart from inflammation of the vein wall in consequence of diseased states of the blood, as in gout and rheumatism, or it may form in consequence of stagnation of the blood-current due to slowing of the circulation in various wasting diseases. When a thrombus forms, absolute rest in the recumbent posture is to be strictly enjoined; the great danger is embolism or the displacement of the clot from its original position. Hot fomentations in the early stages and belladonna ointment when the condition becomes sub-acute are the best local applications. The desire is to promote absorption of the clot. The veins in the lower extremity and in the hemorrhoidal and spermatic plexus are liable to dilatation. The condition is termed varix. The veins dilate with tortuosity; the valves become incompetent; and the condition is apt to spread. In the lower extremity the primary cause may be an injury or some obstruction at a higher point. General laxity of the tissues predisposes to the condition ; occupa-tions which necessitate much standing and alternation of heat and cold also act as predisposing causes. The treatment consists in giving the dilated vessel support by means of an elastic bandage or stocking. When the condition is local and gives discomfort, the vessel may be ligatured at various points so as to cause its oblitera-tion. This operation should not be undertaken rashly, and should only be performed if the case is an aggravated one, since it is by no means devoid of risk. In the hemorrhoidal plexus the disease is termed internal haemorrhoids or piles ; many operations are per-formed for this condition, but in the great majority of cases the careful use of purgatives and the administration of cold water in-jections into the rectum will relieve the condition. The dilated veins often ulcerate and give rise to bleeding piles ; here an opera-tion is often called for, because the persistent loss of even small quantities of blood is apt to result in chronic anemia. The en-largement of the spermatic plexus is termed varicocele, and almost always occurs on the left side. The use of a suspensory bandage and cold bathing should first be tried ; if the disease persists, it is often associated with mental depression, and an operation—ligature at several points of the dilated vessel—should be performed. The disease may be associated with atrophy of the testicle on the same side, and this liability aggravates the mental condition and en-courages the surgeon to operate. Inflammation of the lymphatic vessels in the lower limbs is often associated with inflammation of the veins in the female after delivery, giving rise to the various forms of white leg. Acute inflammation of the lymphatic vessels and glands is also associated with poisoned wounds, and has al-ready been alluded to in connexion with injuries. The use of hot fomentations and careful elastic pressure with rest are prescribed! for treatment.
2. Diseases of Bone. Attention has already been directed to one form of injury to a Bone bone, viz., fracture. A word may now be said about inflammation diseases, of a bone and its results. As a typical instance we will take a long bone, consisting of a shaft and two extremities. The walls of the shaft consist of dense bone, the extremities of cancellated tissue. The shaft of the bone is hollow, and filled with medullary tissue. In the fully developed bone the extremities alone are tipped with cartilage ; in the extremities of the bones of a growing person there are also layers, termed the epiphyseal cartilages. The bone-is surrounded by a fibrous membrane termed the periosteum. This membrane is richly supplied with blood-vessels, which ramify through it and pass, along with lymphatic vessels and nerves, from it into the Plaversian canals in the dense bone forming the shaft. The deeper layers of the periosteum consist of osteoblastic cells, which also line the Haversian canals. In the undeveloped condition these cell elements take an active part in the growth of the bone as regards its breadth, the epiphyseal cartilages taking an active part in its growth as regards its length. The medullary tissue la-the cavity of the bone is supplied by the nutrient artery ; the cancellated tissue forming the extremities receives its blood-supply partly from the nutrient artery and partly from vessels passing in-directly from the periosteum. When a bone is injured—as happens, for example, in a severe bruise—the blood-vessels in the periosteum and in the Haversian canals become congested, effusion of liquor.

sanguinis and migration of the white blood corpuscles take place, and a severe gnawing pain is felt at the seat of the bruise. The pain is severe because the effusion cannot escape. It collects under the periosteum and in the Haversian canals. The cell elements in these situations are irritated, and cell proliferation takes place. The periosteum becomes thickened, and if the tension continues suppuration may occur between the periosteum and the bone. The periosteum is raised from the bone ; the blood-vessels passing into the Haversian canals are obliterated or torn across ; and the outer layers of the hard dense bone, their sources of nutriment being cut off, die. The extent of the necrosed tissue will depend upon the extent of the suppurating area ; if the suppurating area includes the nutrient artery within its range, nutriment being then cut off from the medullary tissue from which in part the deeper layers of the shaft of the bone are supplied with blood, death of the whole thickness of the shaft of the bone may occur. As already stated, the most acute forms of suppurative periostitis and suppurative osteomyelitis are infective diseases, the suppuration in them being due to the presence of a micrococcus. If after an injury the primary inflammation is relieved by fomentations, leeching, or incisions, suppuration may be prevented; or even if, after suppuration has occurred, free incisions are made to allow the pus to escape, the periosteum may assume its normal position, and the area of necrosis be limited or necrosis be prevented altogether. After a portion of the shaft of the bone dies, the necrosed area is gradually absorbed; but, if the area is of considerable size, and more particularly if sepsis occurs, the dead part is gradually separated from the living, and after a time it becomes loose, and as a rule has to be removed by operation. If the inflammation, acute in the first in-stance, becomes sub-acute, or if it is sub-acute from the first, then, instead of suppuration, the effusion under the periosteum coagu-lates, whereupon lymph is formed, the proliferating osteoblastic cells in the lymph take up their normal function, anil new bone is made. This mass of new bone is termed a node. In the Haversian canals the osteoblasts there forming bone will render the bone tissue more dense and ivory-like in consistence, to which the term sclerosis is applied. In some cases the osteoblastic cells in the Haversian canals, instead of forming bone, feed upon the original bony tissue which constitutes the walls of the canals. The Haversian canals becoming enlarged, the result is a lessening of the amount of inorganic matter in the area affected, and a cancellation of the hard bone takes place. This condition is called rarefying ostitis. The rarefaction of the dense bone may persist, or the process may stop, the osteoblasts again forming bone and the rarefied area becoming sclerosed. In the cancellated tissue in the extremities of the long bones, and in that which forms the mass of the short bones, such as the vertebrae, the tarsal and the carpal bones, the inorganic matter compared with the hard bone is relatively in smaller amount than the organic matter filling the cancellse. Here as a result of injury the thin lamellfe of bone may be cut off from their blood-supply, and death take place. If the process is acute, an area of cancellated tissue will die, and be separated from the surrounding living tissue as in the hard bone. In consequence, however, of the quantity of organic matter, death may take place in a molecular form, more nearly allied to the process of ulceration in the soft parts. This condition is known as caries. If the inflammatory process in cancellated tissue is sub-acute, instead of a molecular death, sclerosis of the cancellated tissue occurs. When the cancellated tissue is the seat of inflammation, in con-sequence of its close connexion and intimate anatomical relations with the articular cartilages, they in their turn become implicated, and we have then to deal with disease of the joint. In all cases in which incisions are made to relieve tension under the periosteum, or in which portions of bone are removed to relieve tension in the shaft or in the medullary cavity of a bone, or in which incisions are made to check the progress of inflammatory action in the can-cellated tissue, strict antiseptic precautions must be taken to pre-vent sepsis occurring in the wound.
3. Diseases of Joints. Structure A joint is a complicated organ, and its integrity depends upon a Of joint, healthy condition of the bones which form it, of the articular carti-lages which cover the ends of the bones, and of the synovial mem-brane which supplies the synovial fluid that lubricates the joint. These different structures are closely associated anatomically and physiologically, and disease beginning in any one of them will assuredly, unless checked, gradually extend to the others. The cartilage covering the ends of the bones receives its blood-supply mainly from the bone, and is also to a certain extent supplied at its edges by the synovial membrane. The cartilage being in itself non-vascular, disease does not commence in it; the majority of joint diseases commence either in the synovial membrane or in the bone ; as a general rule they begin with some slight injury of the joint. These injuries consist of strains or twists (of the joint) on the one hand and jarring or contusion on the other. In the latter case the elastic cartilage lessens the force of the contusion.
When a joint is strained, the ligaments binding the bones to-gether are stretched and the synovial membrane becomes inflamed. Sprain. Consequently effusion takes place into the joint, which becomes swollen and painful on pressure. Any movement of it is painful, and all the muscles around it are rigid. In a healthy person appro-priate treatment—rest, hot fomentations, and gentle elastic pressure—will cause the fluid within the joint to be gradually absorbed, after which the joint can be restored to its normal condition. When the inflammation becomes sub-acute the pain disappears, and unless the joint is kept quiet by appropriate splints the condition is very apt to become chronic ; that is, the joint becomes swollen and the omovements are restricted. This condition is most persistent, and prolonged rest, along with counter-irritation by blistering or by the application of tincture of iodine, is necessary before the effusion subsides. The joint may remain weak for the rest of the patient's life. Fibrous adhesions may form and prevent free move-ment. A joint in such a condition is always liable on the slightest injury to have a return of the effusion in an acute or sub-acute form. These are the chief consequences of a strain in a healthy person. In a weakly person the primary strain may entail a very different result. The synovial membrane may undergo gelatinous oi- pulpy degeneration, and, although it is improbable that this condition is associated with the tubercular diathesis in all cases, there can be no doubt that in very many the degeneration of the synovial membrane is tubercular in character. The tubercle bacil-lus has been found in the thickened membrane. A joint in this condition swells; the enlargement, although it may be due in part to effusion into the cavity of the joint, is mainly caused by the thicken-ing of the synovial membrane, which has a peculiar doughy semi-elastic feeling. The movements of the joint are restricted, though little pain is complained of. If it is an upper limb the patient will not use it, if a lower limb he will walk with a distinct limp. The disease is a chronic one, and the joint may remain in this con-dition for months. Rest, elastic pressure, and blistering may check the progress of the disease, but as a rule, sooner or later, and very often as the result of some slight injury, a change takes place. On the one hand, the effusion within the joint, instead of being serous, becomes sero-purulent and even purulent, owing to the formation of pus within it. If the joint is an important one, inflammatory fever is set up ; the joint becomes intensely painful on the slightest movement, and unless incisions are made to allow the pus to escape it passes gradually into a state of complete dis-organization. The cartilage softens and breaks down, so that gradually the cancellated bone underneath is exposed. A similar change takes place in the opposing cartilage. It is destroyed in its turn and the ligaments binding the bones together are softened and lose their elasticity, so that the joint can be moved in abnormal directions. A grating sensation can be felt when the cancellated bony surfaces are rubbed together. Along with these changes within the joint, foci of inflammation form in the soft tissues around it. These inflammatory areas suppurate ; the abscesses burst into the joint; the skin over them gives way; and com-munication is established between the external air and the cavity of the joint. Through this channel the causes of putrefaction reach the cavity, and complete disorganization of the part accom-panied by sepsis occurs. Should the joint be an important one, a condition termed hectic is set up. If the discharge is allowed to continue, a gradual wasting takes place, which sooner or later ends in the death of the individual, unless the surgeon either re-lieves the tension by free incisions, or excises the joint, or amputates the limb. After disorganization has occurred, if the inflammatory process ceases, anchylosis of the joint may result. But, if the joint is freely drained and kept at rest, the inflammation will subside, and the granulation tissue on the two opposing surfaces will unite and a fibrous formation take place. The process may stop there, or the fibrous tissue may be gradually transformed into bone. Osseous union has taken place between the hones forming the joint. In many cases this is what the surgeon aims at, and it is of great importance to keep it constantly in view and to place the joint in such a position that, if anchylosis does occur, the limb may be as useful as possible. This result is only attained after prolonged treatment, and, if the patient's strength is unequal to it, it will be necessary to excise the affected joint or to amputate the limb. Suppuration sometimes occurs within a joint without any previous pulpy degeneration of the synovial membrane, either as the result of a wound or from septic inflammation secondary to pyaemia, or in consequence of a very acute simple synovitis resulting from excessive tension within the joint. When the synovial membrane is affected with pulpy degeneration the vitality of the cartilage at its edges, wdiere it joins the synovial membrane, may be interfered with: the thickened synovial membrane, by encroaching on the articular cartilage, gradually by pressure alters the nutrition of the cartilage so that it disintegrates and breaks down, and when it is destroyed disorganization of the joint ensues, as already described. Should the disease assume this form, if care is taken, and if the joint is kept quiet, suppuration within it need not necessarily take place. The inflammation may assume a sub-acute type and fibrous anchy-losis occur.

"When a joint has been severely contused, separation of the cartilage
tusion. from the bone occurs ; effusion then takes place between the carti-lage and the bone; the cartilage is cut off from its nutrient supply; and, unless the joint is kept at complete rest, unless the effusion is absorbed, the cartilage will sooner or later become necrosed. The necrosed cartilage will give way ; the bone beneath will be exposed ; and, if the irritation is kept up, effusion, at first serous but soon becoming purulent in consequence of the tension within the joint, will take place. Changes follow in the opposing carti-lage, which has been itself bruised by the primary jar, and perhaps even separated from the bone beneath. It will in its turn necrose, and the bone will be exposed, suppuration taking place within the joint. The synovial membrane will become diseased, the liga-ments softened, and the evil sequence of events already described will ensue. A joint affected in this way is easily recognized from one in which the synovial membrane is primarily affected by the absence of swelling and by the intense pain. In the early stages complete rest should be obtained by affixing a weight to the affected limb. This, by setting up between the opposed and in-jured cartilaginous surfaces a condition of negative pressure, will tend to check the disease. But if this plan of treatment does not soon cause a subsidence of the pain, actual cautery must at once be resorted to. Contusion in wdiich the cancellated bone is injured at some distance from the cartilage is most commonly met with in young people, in whom the extremities of the bones are not fully developed. In them the epiphyseal cartilages are richly supplied with blood for the performance of their physiological function, the formation of bone, and a comparatively slight in-jury may cause inflammation to be set up in the bone immediately in contact with the epiphyseal cartilage. As in the synovial mem-brane when it is affected with pulpy degeneration, this disease may be occasionally non-tubercular in character ; but in the majority of cases, more especially when the primary injury is very slight, the disease assumes the tubercular type and tubercle is deposited. In such cases the symptoms are often very insidious ; the young patient complains of some slight uneasiness, or the first thing to be noticed is a limp in walking when a lower limb is affected. In the case of an upper limb the patient will avoid moving the affected joint. As there is no external swelling, the disease may be overlooked in its early stages ; but, if it is suspected, and if the affected limb is kept at rest, the inflammation will subside and recovery ensue. On the other hand, if the patient is allowed to use the limb, even in an imperfect way, the tubercular area may extend and the articular cartilage become affected. The articular cartilage does not in that case receive its proper nourishment: it disintegrates, breaks down, and the disease attacks the joint. Into this last tubercular matter escapes and suppuration occurs, result-ing sooner or later in disorganization of the joint.
In recent years a useful limb has often been saved by excision of the affected joint. In the early stages the disease may subside under appropriate local treatment, such as counter-irritation, rest, pressure, assisted by constitutional treatment, such as tonics, fresh air, and careful dieting. By these means an operation may be avoided, and in applying such treatment it must be remembered that, wdiile the disease itself may subside, the joint as an organ may Anchy- be irretrievably damaged: it may become anchylosed. If anchylosis losis. occurs in a flexed position of the hip or knee joints, the limb will be useless for progression ; and an operation will be necessary in order to straighten it. In the ankle joint, if anchylosis occurs with the foot in an extended position, the patient will not be able to put his heel to the ground, and an operation will be necessary to bring the foot at right angles to the leg. Do not interfere with an anchylosed joint in the lower limb if it is in good position. If the shoulder joint becomes anchylosed after disease, the sterno-clavicular and acromio-clavicular joints take up to a great extent the function of the anchylosed shoulder. In the elbow, in what-ever position the joint becomes anchylosed, the arm loses much of its usefulness and excision of the joint is performed in order to get a movable elbow. In the wrist it may be necessary to operate for anchylosis ; but as a rule, if the fingers are mobile, the anchylosed wrist does not interfere to any great extent with the usefulness of the hand.

4. Venereal Diseases. Bela- Three distinct affections are included under this term—gonorrhoea, tions of chancroid, and syphilis. At one time these were regarded as dif-venereal ferent forms of the same disease ; and, though gonorrhoea is now diseases, generally held to be quite distinct from the other two, there are not wanting eminent authorities, including Mr Jonathan Hutchinson, who are inclined to look upon chancroid and syphilis as essen-tially one and the same disease. The present writer believes that gonorrhoea, chancroid, and syphilis are three distinct diseases, due to separate causes, which have nothing in common except their habitat. The cause in each case is a specific virus, probably a micro-organism. In the case of gonorrhoea the virus attacks mucous membranes, especially that of the urethra ; in chancroid mucous membranes and the skin are affected ; in syphilis the whole system comes under the influence of the poison. Gonorrhoea
and chancroid correspond to the process of septic intoxication. The organisms on implantation set up a local disturbance, and the products of this fermentative process pass into the system and give rise to constitutional effects ; but the organisms themselves do not pass into the system generally. In syphilis, on the other hand, there is a true infective process: the organisms pass into the general circulation and live and multiply wherever they find a suitable nidus. The joint affection commonly called "gonorrheal rheu-matism," which sometimes follows gonorrhoea, is in all probability an infective condition. If this is true, then in these rare cases gonorrhoea is infective. The chancroid poison may pass into the lymphatics and cause inflammation of the lymphatic glands in the groin, giving rise to chancroidal bubo. These clinical facts are undoubtedly opposed to any generalization such as that laid down above, and it is right to note them ; but the general comparison between gonorrhoea and chancroid as non-infective and syphilis as distinctly infective in its character holds good in the great major-ity of cases. A further study of these quasi-infective varieties of gonorrhoea and chancroid must undoubtedly throw light upon the physiological classification of pathogenic organisms. These three affections are generally acquired as the result of impure sexual intercourse ; but there are other methods of contagion, as, for example, when the accoucheur is poisoned whilst delivering a syphi-litic woman, the surgeon when operating on a syphilitic patient. An individual may be attacked by any cne or any two of the three, or by all of them at once, as the result of one and the same connexion; but they do not show themselves at the same time ; in other words, they have different stages of incubation. In gonorrhoea the disease appears very rapidly, so also in chancroid, the first symptoms commencing as a rule three or four days after inoculation. It is very different, however, with syphilis. Here the period of incubation is one rather of weeks, the average length being twenty-eight days, though it may vary from one week to eight. The length of the period of incubation, therefore, is the great primary diagnostic in the case of syphilis.
Syphilis is an infective fever, and its life history may be best Syphilis, considered by comparing it with vaccinia. A child is vaccinated on the arm with vaccine lymph. Tor the first two or three days nothing is observed ; but on the fourth day redness appears, and by the eighth day a characteristic vaccine vesicle is formed, which bursts and frees a discharge, which dries and forms a scab. If on the eighth day the clear lymph in the vesicle is introduced at another point in the child's skin, no characteristic local effect follows. The system is protected by the previous inoculation ; this protection will last for some years, and in certain cases for the rest of the patient's life. We have here, then, exposure to a poison, its introduction locally, a period of incubation, a charac-teristic local appearance at the seat of inoculation, a change in the constitution of the individual, and protection from another attack for a variable period. So with syphilis. The syphilitic poison is introduced at the seat of an accidental abrasion either on the genital organs or on any part of the surface of the body. The poison lies quiescent for a variable period. The average period is four weeks. A characteristic cartilaginous hardness appears at the seat of inoculation. If this is irritated in any way, an ulceration takes place ; but ulceration is an accident, not an essential. From the primary seat the system generally is infected. The virus is multiplied locally and, passing along the lymphatic vessels, attacks the nearest chain of lymphatic glands. If the original sore is in the genital organs, the glands in the groin are first attacked ; if in the hand, the gland above the inner condyle of the humerus ; if on the lip, the gland in front of the angle of the jaw. The affected glands are indurated and painless; they may become inflamed, just as the primary lesion may ulcerate; but the inflammation is an acci-dent, not an essential. From the primary glands the mischief will affect the whole glandular system. The body generally is so altered that various skin eruptions, often symmetrical, break out. Any irritation of the mucous membrane is followed by superficial ulcer-ations, and in the later stages of the disease skin eruptions, pustular and tubercular in type, appear, and in weakly people in severe cases, or in cases that have not been properly treated by the surgeon, syphilitic deposits termed gummata are formed. These, if irritated, break down and give rise to deep-seated ulcerations. Gummata may attack the different organs in the body ; the muscles, liver, and brain are the favourite sites. Their presence interferes with the functions of the organs, and, if the organ affected is one functionally important in the economy, may cause death. The individual is as a general rule protected against a second attack, although there have been rare cases recorded in which individuals have been attacked a second time.
Syphilis is treated by many surgeons by giving careful attention Treat-to the general health, to diet and regimen and tonics, by placing ment of the patient in the most favourable hygienic circumstances, in the syphilis, belief that it runs a natural course and has a tendency to natural cure. Special symptoms are treated as they arise. Other surgeons administer small doses of mercury, in the form of grey powder, iodide of mercury, or corrosive sublimate. If the physiological

effects of mercury are observed—tenderness of the gums and a metallic taste in the mouth—this treatment is desisted from and iodide of potassium is administered, mercury being given again when its physiological symptoms have disappeared. Oleate of mer-cury or mercurial ointment, or mercury with lanoline, is applied to the primary lesion and rubbed in over the enlarged glands. This is continued for six months or a year. In the later stages of the com-plaint iodide of potassium is the main remedy used. There are therefore two distinct methods of treating syphilis,—the non-mer-curial and the mercurial. Both methods have been extensively tried by the present writer, and he believes that the mercurial is infinitely preferable to the non - mercurial method. Recent investigations point to the value of corrosive sublimate as a germicide, and in all probability the good results which follow saturation of the system with mercury are to be explained in this way. It is said by the non-mercurialists that the administration of mercury masks the symptoms. There can be no doubt that the symptoms often appear after the mercury is stopped, but in a modified form, and there is no evidence that the mercurial treatment prolongs the disease. Syphilis has a tendency to natural cure, like all the continued fevers, and along with the administration of mercury careful hygienic treat-ment must receive particular attention, and often in weakly un-healthy people a long sea voyage is of great value. Any means which causes a free action of the skin, as, for instance, by periodic visits to thermal baths, is of great assistance in eliminating the poison.
Syphilis as commonly met with nowadays is not of so severe a type as it formerly was. One reason often given for this is that mercury was formerly always pushed until its full physiological effects were observed, and that the lowering of the patient's con-stitution by this severe treatment aggravated the primary com-plaint. There may be some truth in this explanation ; but the principal reason in all probability is that the syphilitic organism does not now find so suitable a nidus or soil for its growth and development as it once did. Syphilis in the United Kingdom at the present moment is in the stage of an epidemic in its decline. This may be looked on as a startling statement; but it is true of syphilis as of all infective diseases. A time must come when the soil is practically worn out, when it becomes so poor that the organ-ism grows only in a stunted form, producing a mild disease, till in time it ceases to grow altogether. It is not asserted that it will necessarily die out, because after lying fallow for a time the soil may recover its power and the disease be revived in a more virulent form, analogous to the luxuriant crop which follows after a period of fallow. Syphilis can be conveyed by the discharge from any syphilitic lesion occurring within two years after the commence-ment of the complaint. It cannot be conveyed by the normal secretions of the syphilitic person except in the case of the semen, which, impregnating the ovum in the female, causes the foetus to be syphilitic. Syphilization of the foetus is followed by syphiliza-tion of the mother. The blood of a syphilitic person is infectious for two years after the commencement of the attack. Pure vaccine lymph cannot convey syphilis ; if, however, it is mixed with blood it may convey it. No person who has had syphilis should marry until he has been entirely free from the complaint for two, or better still for three, years. If a person marries before this time pregnancy greatly increases the risk to the mother. If there is any suspicion of syphilis the mother should take mercury during the period of pregnancy. It is interesting to note how time has a modifying influence in a case of repeated pregnancies occurring in a syphilitic woman. At first there may be miscarriage in the early stage of pregnancy; after a time abortions in the later stage ; there may then be a still-born child; then one born alive but syphilitic; then a child born apparently healthy but soon becoming syphilitic; and ultimately a healthy child is born and remains healthy, showing no evidence of syphilitic disease. The disease has worn itself out. The relation of apparently healthy people born of syphilitic parents to syphilis acquired during the course of their life may explain those remarkable cases of escape from syphilitic infection which constantly come under the observation of the surgeon.

5. Tumours.

Cause of As the result of a local irritation an acute inflammatory swelling tumours, may appear. If the irritant is of a severe type the result may be local death. An abscess may form ; and, after the pus has escaped or has been evacuated, and after the original cause of the irritation has subsided, the swelling may disappear and the parts be restored to a condition nearly allied to the normal. If the irritant, however, is slight and its action prolonged, a chronic inflammatory swelling of the part may result. Although in many cases with appropriate treatment the induration disappears, in other cases it persists during the life of the individual. The indurated mass in its microscopic characters closely resembles the original anatomical characteristics of the part affected. When, for example, an organ like a gland is the seat of a chronic irritation a general increase in its size takes place. A hypertrophy or overgrowth has occurred, hut as a rule the hypertrophied gland is only altered in size ; it retains its general shape and functional activity. Occasionally the hypertrophic area is localized, and to a great extent separable from the original gland by a more or less distinct capsule. In the mammary gland, for Various example, a local hypertrophy may occur, the microscopic characters forms of of which resemble imperfect gland tissue. Between this condition tumour, and an adenoid or glandular tumour of the mamma no distinct line of demarcation can be drawn, and the probability is that the ade-nomatous tumour of the mamma is caused by local irritation. It may be the immediate outcome of a misdirected or excessive functional activity. The great practical difference, however, between it and true hypertrophy is this, that it can only be removed by operation. The adenomatous tumour closely resembles in some of its microscopic characters one of the varieties of epithelioma, of which an increase in the columnar epithelium lining the acini in the gland is the main characteristic. This tumour is not a simple tumour like the true adenoma ; it does not grow slowly ; it is not encap-sulated ; the cellular elements in it not only invade the surrounding tissues but tend to pass into the lymphatic vessels and reach the lymphatic glands in the arm-pit, where they grow and form second-ary tumours similar in microscopic characters to the original growth. From these secondary foci a further invasion may take place, and the cell elements may reach the blood-stream and be caught in the capillaries, forming there new growths, till the patient dies from the general implication of the whole system. This form of tumour has been termed a malignant adenoma. While it has originally the microscopic characters of a simple adenoma, if we look to its life history we have in it an excellent example of a malignant tumour. Microscopically it is a stepping-stone between the simple and the malignant type of tumour ; clinically it is characteristically malig-nant. The mammary gland is composed of glandular tissue and fibrous tissue. A hyperplasia of the fibrous tissue may occur in consequence of an excessive irritation of the glandular tissue, or apparently a primary increase in the fibrous tissue may occur locally, giving rise to a simple fibrous tumour of the mamma, of which fully developed fibrous tissue is the microscopic characteristic. This overgrowth may become encapsulated and give rise to no symptoms except those referable to its gradual increase in size, and after the gland in which it lies has fulfilled its life history it may stop growing, degenerate, and decay. In the uterus, e.g., those fibrous tumours which occur after the time of child-bearing is past, after the uterus has fulfilled its destiny, cease to give any further trouble and are only inconvenient in consequence of their size. Fibrous tissue in the early stages of its development is largely composed of cell elements, and there are tumours, e.g., in connexion with the mamma, which have their prototype in the undeveloped or cellular stage of fibrous tissue. These tumours also are essentially malignant. They grow rapidly, and are richly supplied with thin-walled blood-vessels ; the elements of the tumour pass directly into the blood-stream, and reach the capillaries, where they are arrested and where secondary growths like the original growth in their anatomical characteristics are formed, causing the death of the patient.
In what has just been said it will be seen that there is no distinct line of demarcation between the inflammatory swelling and the hypertrophy, between the hypertrophy and the tumour proper, between the simple and the malignant tumour. The local irrita-tion can be traced in the case of the inflammatory swelling and the hypertrophy, and it is highly probable that both the simple and the malignant tumour are also due to local irritation. It must, however, be acknowledged that it cannot always be traced. If the malignant tumour is not due to local irritation, but to a general dyscrasia or peculiarity of the patient, the surgeon has slight grounds for recommending its removal. If, however, he believes that all tumours are evidences of local irritation, he is fully justified in recommending their early and complete removal—in the case of the malignant tumours before they have time to spread by the lymphatic or blood-stream to distant parts, in the case of simple tumours before they have assumed characteristics of malignancy, as these tumours sometimes do. The mammary gland has been taken as an example of an organ in which tumours frequently occur. The reason for this frequency, if we believe in local irritation as a cause of tumour-growth, is not far to seek : from the time of puberty to the time when it terminates its functional activity this gland is in a constant state of vascular unrest and functional change. Both forms of tu-mour are met with in all the organs and tissues of the body. Simple tumours are generally composed of fully developed tissue, similar to the tissue in which they lie, the simple fatty tumour occurring in connexion with fatty tissue, the simple fibrous tumour in con-nexion with fibrous tissue, the osseous tumour in connexion with bone. The malignant tumour, on the other hand, is generally formed of undeveloped tissue wdiieh has not yet fulfilled its destiny, which is not only misplaced in situation but in time. The carti-laginous tumour has its prototype in cartilage, for that which covers the ends of the long bones and enters into the formation of a joint is a fully developed tissue. The true prototype of the cartilaginous tumour is not, however, fully developed cartilage, but one or other of those forms of cartilage which, as regards their developmental

position, are intermediate between fibrous tissue and bone, and therefore the cartilaginous tumour has frequently a life history more closely allied to the malignant than to the simple type of tumour formation.
No attempt can here be made to classify the different forms of tumour. The surgeon at the bedside meets with tumours as living parasitic formations. He studies their life history ; he observes their birth, their growth, their peculiarities, and their tendencies ; he naturally attempts to classify them from a study of their physio-logical or clinical aspects. The pathologist, on the other hand, examines the tumour after it is removed ; he studies it as it appears to the naked eye and under the microscope ; and he attempts to classify tumours from an anatomical standpoint. Within recent years the pathologist's classification, associated with a recognition of the developmental division of the human embryo into different layers, has become the favourite ; but it is hoped that, as science advances, the increase of clinical knowledge, assisted by microscopic and embryological research, will make a physiological classification a reality.

IV. OPERATIVE SURGERY.

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.)

1. Cranial.

The necessity for setting apart a distinct section of this article to deal separately with the region of the head does not depend upon any specialization in the principles of treatment peculiar to that region. The general laws of surgical procedure hold good here as elsewhere throughout the body; but they have to be exemplified in relation to a region so separated from others in its architectural and functional peculiarities as to call for special record and delinea-tion. The surgeon has to deal with a most intricate series of considerations— anatomical, physiological, and psychic—in devising suitable treatment for abnormal conditions in this region; the inter-relation of cranial tissues and organs, their capital importance in the physical economy, and the position of some of them as the sub-strata of mental activities render any surgical interference a matter of great delicacy and grave anxiety. So much is this the case that it has been left for the most daring and the most modern surgeons to prove that this is a region to which ordinary surgical rules may properly apply; and hence what must be here recorded is largely matter of quite recent history and to a large extent at variance with the doctrine of former epochs. The function of the Function cranium as a protective agent for the brain and the organs of of the special sense is strikingly shown by its architectural design. The cranium, proper discharge of this function is of paramount importance from the economic value of the cranial contents ; and the demands upon it are the more exacting from the extreme delicacy of physical structure and the unstable physiological equilibrium present in the brain. Clothed externally by the densely resisting textures of the scalp, further protected by a layer of heat-deflecting hair, the cranium itself consists of a firmly welded bony casket of ovoid form, maintained in its balanced position upon the upright spinal

column by a series of ligamentous and muscular bands. There is thus protection against the sun's rays and a general mobility that provides for the avoidance of impending blows. But the cranium has chiefly to receive and annul transmitted physical vibrations, the result either of blows upon the head or of those jars and oscillations, incidental to bodily movements, which would interfere greatly with the functions of the brain did they actually Protect- reach it. The function of the cranium in this respect has been ive me- fully described by Hilton, who shows that special bony ridges ehanism. are "present in the skull which arrest vibrations and divert them into channels where their action is no longer deleterious. Three series of such buttresses descend from the vault to the base of the skull, where they converge in the region of the sella turcica at a point termed by Felizet "the centre of resistance," and where the terminations of the ridges come into immediate contact with the cartilage of the foramen lacerum medium or the lake of cerebro-spinal fluid which surrounds the anterior and posterior clinoid pro-cesses. The transmitted vibrations are thus annulled by transfer-ence to a liquid or a soft solid medium, and lose all further power. In addition to the special mechanism which mitigates the effect of considerable shocks and renders slight ones ordinarily imperceptible, there is a general elasticity of the skull which enables it to with-stand great violence without material injury and so enhances its protective power. This elasticity is not uniformly present, but is much more developed in the bell-like vault than in the region of the base. The osseous texture also is much more brittle in the latter locality. When, therefore, such severe shocks are communi-cated to the skull as overcome its elasticity and its power of resist-ance, the fracture which ensues is found as a rule to involve the base much more seriously than the vault. Effects of These physical qualities are of great importance as giving an violence, index of the relative resisting powers of different parts of the skull, and as affording data that may assist in determining the position of a fracture from a study of the forces which caused it. Of such forces those that are closely circumscribed in their area of appli-cation produce strictly local effects, whilst diffuse blows produce their most marked effects at a distance from their point of applica-tion. The former fact needs no illustration ; the latter has been made the subject of numerous researches in relation to the usual course of cranial fractures. From the results of these investigations three different etiological laws have been educed—(1) Saucerotte's law of contrccoicp ; (2) Aran's law of radiation ; and, in special re-lation to fractures of the base of the skull, (3) Von Wahl's law of parallel cleavage. In its special sphere each of these laws probably holds true ; but the sphere of each is a limited one and is dependent upon the local peculiarities of the skull already described. The Theory theory of contrecoup is that a force produces its maximum effect at of contre- the opposite pole of the skull to the point of its application. That coup. this law can have no general bearing is shown by the numerous cases in which the fracture bears no such relation to the force which causes it. In relation to a limited area of the vault, however, it appears to hold true ; for isolated fractures of the base resulting from blows upon the vault are on record, but as these are the only fractures which this theory would explain, and as they are very rare, its range Law of of action is very greatly curtailed. Aran's law of radiation is that, radiation, starting from the point where the blow is received, a fissure traverses the walls of the skull in the direction of the base and spreads itself in that fossa of the base of the skull which corresponds to the part of the vault that is struck. Thus a diffuse blow on the frontal bone causes injury to the anterior fossa of the base, and blows upon the parietals or occipital bone cause similar injury to the middle or posterior fossa respectively. This law holds true of the great majority of fractures of the skull and will assist in localizing the course of a fracture wdien the part of the skull first struck can be Law of recognized. But numerous cases of fractured base are on record parallel in which no fissure can be traced leading from the point first struck ; cleavage, and from a study of these Von Wahl has concluded that fractures of the base, whether connected with fissured vault or isolated, are always parallel to the direction of the force which caused them. Thus blows upon the frontal and occipital regions cause longi-tudinal fissures of the base, in the temporal region oblique fissures, and in the mastoid region transverse fissures. An index of the probable direction of a fracture is thus obtained by observing the exact point of incidence of the blow which caused it, whether other evidences of localized injury to the cranial contents be forthcoming or not. Symp- The diagnosis of the presence of a fracture is often a matter of toms of great difficulty, especially where the soft parts are still intact, and fracture, by their contused and swollen condition mask the true nature of the case. Apart from obvious external signs of injury, the following symptoms should lead to the suspicion of a fracture:—bleeding from the mouth, nose, or ears ; local ecchymoses or lacerations, as that of the membrana tympani; circumscribed haemorrhages, as under the scalp or visceral conjunctiva ; interference with the func-tions of the brain or special sense-organs, as aphasia, motor spasms or paralyses, blindness, deafness, an altered condition of the respira-tion or the pupils, slight unconsciousness or profound stupor. The immediate risks to life are from shock and compression, the latter due to depressed bony fragments or effused blood. The treatment of shock has already been alluded to (p. 680 above); that of com-pression consists in the early relief of pressure by trephining, with Question elevation of the depressed fragments and removal of the blood-clots, of tre-if the symptoms are advancing. These symptoms are increasing pinning, stupor, stertorous respiration (Cheyne-Stokes breathing), relaxation of sphincters,—the condition passing on to complete coma. In cases where pressure symptoms are not urgent (especially in young patients with elastic skulls) and in cases where no such symptoms are present, expectant treatment should be employed,—complete rest, local cooling applications, constantly applied, the exclusion of all stimuli to the special sense-organs or to the attention, and a careful watch for further symptoms. Should symptoms of compres-sion appear and advance, or should slight symptoms already present become aggravated, immediate operative interference for the relief of pressure as above indicated must be resorted to, and in operat-ing in this region it must be remembered that strict antiseptic pre-cautions are essential, for in no region of the body—not excluding even the peritoneal cavity—are the effects of septic infection more disastrous and at the same time so hopeless of remedy.
Having thus alluded to the physiology and surgery of the cranial Topo-envelope, it remains to consider the corresponding aspects of the graphical cranial contents. The older theory of Flourens and Hertwig, that areas of all parts of the brain are equally concerned in producing its aggregate brain, activities, has been displaced by the more recent theory of the localization of function. This theory is supported by the results of recent physiological and pathological investigations, the former carried on for the most part by Hitzig, Fritsch, and Ferrier, the latter by Broca and Meynert. The practical outcome of these re-searches—viz., an adaptation to the human brain of results obtained in that of the higher mammals, controlled by pathological observa-tions on the human brain itself—is that the surface of the brain can be mapped out into a series of topographical areas, each of which occupies a definite relationship to some well-defined function— motor, sensory, or psychic—of the human economy. Of the areas connected with psychic activity little is at present known ; they are generally believed to occupy the frontal lobes of the brain. In Localiza-the parietal region grouped around the fissure of Rolando are the tion of cortical areas connected with motor functions in the extremities, function, and around the horizontal limb of the fissure of Sylvius are arranged those concerned in general and special sensation. The results of these researches confirm the views of Hughlings-Jackson, who has conclusively demonstrated the cortical origin of those epileptiform seizures in which the motor phenomena are limited to particular groups of muscles. At the same time these results open a new field of anatomical and surgical inquiry, with the object of defining what relation the cerebral convolutions bear to external cranial land-marks, and of showing that circumscribed cortical disease or injury is capable of detection and relief. For practical purposes in the Relation present state of our knowledge of cerebral physiology, the first of con-part of the question limits itself to an exact delineation of the volutions position of the fissures of Rolando and Sylvius in relation to well- to sur-known cranial landmarks. In regard to the position of the former face of several researches have been made, and its upper extremity has head, been localized at a point 2 inches behind the coronal suture in the mesial line by Broca, Turner, and Fere. For the purpose of its exact determination in the living subject, where the line of the coronal suture cannot always be detected, measurements have been made and formulae for its localization devised by Giacomini, Lueas-Championniere, Hare, and Rcid (see the literature cited below). The commencement of the fissure of Sylvius is situated 1J inches behind the external angular process of the frontal bone.
As an outcome of these additions to our knowledge of accurate Trephin-facts, a new branch of surgical procedure is now firmly established ing for and already sufficiently supported by successful results, viz., trephin- cortical ing for the relief of cortical disease. Encouraging cases have disease, occurred in the hands of Hughes Bennett and Godlee, Fraser and Chiene, and Victor Horsley. The last-named presented to the British Medical Association meeting in 1886 three patients relieved by this operation from cortical lesions. As a result of wide ex-perience in operating upon apes and upon human beings, Mr Horsley accentuates the importance of employing the following precautions in operative interference :—(1) thorough cleansing and disinfection of the scalp; (2) the use of chloroform as an anaesthetic, morphia having been previously given to reduce cerebral congestion and to obviate excessive haemorrhage during the operation ; (3) strict antiseptic precautions ; (4) a semilunar incision through the soft parts ; (5) the use of large trephines ; (6) Macewen's method of replacing the bone in small fragments carefully purified. The occurrence of hernia cerebri signifies a failure in the antiseptic pre-cautions, and a primary union of the integuments is a matter of the most extreme importance. In removing the tumour or scar-tissue the knife is preferable to the thermo-cautery.1 (A. W. H.)

1 Literature of Cranial Surgery.—Perceval Pott, Injuries of the ITead; Sir Astley Cooper. Led. on Surgery (Tyrell), vol. t Sir B. Brodie, Med. Chir. Trans., vol.


2. Thoracic.

Purulent collections in the pericardium and pleural sacs may he treated as ordinary abscesses by incision. In the case of the pleural cavity the pus may be evacuated through an opening made in the axillary line at the seventh costal interspace ; but it is imite possible to empty it thoroughly at the fifth. A drainage-tube is inserted, protected by a broad flange, that it may not slip into the cavity, and strict asepsis should he secured. Should sepsis occur, the wound should be washed out, and a counter-opening made if necessary. As the lung, however, frequently will not expand, and a large cavity is therefore left to heal by granulation, with little chance of it ever getting filled up, surgeons have excised portions of the ribs in order to bring about a collapse of the chest wall and thus ensure obliteration of the cavity. The second, third, fourth, fifth, and sixth ribs have been partially removed, together with a portion of the clavicle. It is better in young people to remove the periosteum also. Some surgeons cut away the thickened pleura as well. The possibility of opening into the pleural sacs and peri-cardium for the removal of tumours has been demonstrated by Kônig and Krister, who have reported cases where growths in connexion with the sternum and ribs were successfully removed. Special care was taken that as little air as possible should gain access to the pleural cavities. Attempts have also been made to tap and wash out vomicae in the lung, but as yet operative interference in such instances is not fully established.

3. Abdominal.

Modern surgery has made its greatest advance and has achieved its most signal triumphs in connexion with operations performed in those cavities of the body which are lined by a synovial or serous membrane. The older surgeons did not dare to systematically attack the joints and the cranial, thoracic, and abdominal cavities ; but the surgeon of to-day performs the most daring operations hero with confidence, and is rewarded with a success which at first sight appears almost marvellous. The timid extraperitoneal manipula-tions of former days made use of in the treatment of hernia and kidney disease and in the formation of artificial anus, have now given way to systematic intraperitoneal modes of treatment, where-by we aim at the radical cure of hernia and bring disease affecting any of the abdominal viscera directly under our control. We have Peri- to consider the conditions under which wound treatment of the toneal peritoneum is placed, and in wdiat respect this portion of the human wound framework reacts upon injuries as compared with the general he-treat- haviour. It is generally acknowledged that rest in the surgical ment. sense, the factor necessary for healthy wound closure, is obtained by a condition of asepsis and fixation. Moreover, it is generally granted that tension as a condition of unrest is dangerous not so much in itself as in the character of the material that gives rise to tension ; hence the extravasated serum and blood in a case of simple fracture give rise to comparatively little disturbance. The presence of ascites need not lead to fever. But once let sepsis gain entrance and the fermenting exudate is resented by the organism ; violent attempts to throw it off are made ; and forms of blood-poisoning more or less severe and variable ensue. In a severe injury of the extremities, say a compound fracture, the effused serum and blood-clot are not readily removed by the damaged lymphatic system, and, when that does act, sepsis having already occurred, the ab-sorption of the putrid fluid does much harm. Fortunately the open character of the wound may allow the foetid discharge to escape. In any case, the surgeon ensures a good result when he makes use of splints, drainage, and antiseptics. He brings about local fixation, removes the excessive exudation, and so relieves the . lymphatics and prevents sepsis. In the case of a penetrating abdo-minal wound, where the healthy peritoneum is injured, we have somewhat different conditions, mainly varying in degree. It must ever be borne in mind that here we open into a huge lymph-sac. The peritoneum consists of a sheet of vascular and lymphatic network, covered with epithelium and provided with stomata. It is easily injured, and then rapid effusion ensues. Like most vascular struc-tures, however, it heals quickly with favourable surroundings, and, the source of irritation having been removed, it speedily returns to ihe normal. In comparison with the large absorbing surface the injured portion is but small, and the effusion thrown out at the seat of injury may readily enough be absorbed by the remainder of

xiv. ; Hilton, Lectures on the Cranium ; Felizet, Recherches anat. et exper. sur les fract. du crâne. 1S73 ; Aran, Arch. Gin. de Med., 4th ser., vol. vi. p. ISO ; Saucerotte, Mélanges de Chirurgie, part i. p. 233, Paris, 1S01 ; Von Walil, " Fracturen der Schàdelbasis," in Volkmann's Series, No. 22S ; Flourens, Les propriétés et les fonc-tions du Système Nerveux, Paris, 1S24; Hitzig and Fritsch, in Reichert and Du Bois Reymond's Archiv, 187*0; Hitzig, " Ueberden heutigen Stand der Frage von der Localisation," in Volkmann's Series, No. 112 ; Ferrier, Functions of the Brain, 1S76, and West Riding Reports, vol. iii., 1S73 ; Hnghlings-Jackson, Lond. Hosp. Rep., 1864, and Clin, and Phys. Researches, 1873; Broca, Sur la topographie cranio-cérébrale, 1876 ; Turner, "Relations of Convolutions to Skull and Scalp," in Jour, Anat. and Phys., 1S73 ; Giacomini, Topografia della Scissura di Rolando, 1878; Lucas-Champiannière, La trépanation guidée par les localisations cérê-irales, 187S ; Hare, Jour. Anat. and Phys., January 1S84 ; Reid, Jjincet, vol. ii., 1884, p. 539 ; Hughes Bennett and Godlee, Brit. Med. Journ., May 1885 ; Victor Horsley, Brit. Meti. Journ., vol. ii., 1886, p. 670.

the healthy sac. So long as the rate of absorption equals that of effusion tension cannot exist. If, however, the nature of the fluid be of importance, it is evident that nowhere in the body is this more marked than in the case of the peritoneum, and here above all other parts must we preserve strict asepsis. This may be gained in vari-ous ways. (1) By drainage, in which case the surgeon carefully draws off from the pouch of llouglas any excess of fluid thrown out as the result of injury, until such time as the peritoneum itself has recovered its full absorbing power and the excessive secretion has ceased. (2) Where by careful sponging the operator so far relieves the peritoneum and then, closing the wound to prevent entrance of further sepsis, leaves the rest to nature. For, if we do permit a moderate septic inoculation, it is evident that the rapid change of fluid may prove inimical to the development of septic ferments and the contact of healthy tissue will finally render impossible the existence of organisms. The presence, however, of any accumula-tion of putrid effusion is at once resented by the peritoneum and an attempt by local peritonitis may shut off the collection, or even previous to any local reaction septic absorption may prove fatal, or again severe general peritonitis may kill the patient. (3) From the above we at one* see how applicable the antiseptic system must be to the abdomen, and the most signal success has crowned atten-tion to matters of detail in this respect. By means of antiseptics we can securely close the abdomen, resting assured that the peri-toneum is perfectly capable of carrying off effusions due to our interference. Where we dread that oozing may complicate matters, the drainage-tube can in addition be employed, but the necessity for its use becomes less marked as the operator acquires experience. Abdominal surgery requires from beginning to end the utmost care, and it is well that specialists reached a high standard of success before the adoption of the antiseptic system, since various points have been formulated, all of which, however, are of minor import-ance compared with the one great end in view,—that of asepsis from first to last. The utmost care should be taken to ascertain the general bodily condition of the patient, to see that the kidneys are healthy, and to select an anesthetic suitable to the requirements of the case. The temperature of the room, the clothing during operation, rapid dexterous manipulation, and preventives against hemorrhage require the utmost attention. The patient should be prepared by having had low diet and gentle purgatives for a few days prior to surgical interference, so that rest of the intestinal tract may readily be assured. As a material for ligature fine silk Chinese twist, of various sizes, may be employed. It must be care-fully disinfected by boiling, and is readily preserved pure in a five per cent, solution of carbolic acid. The ends should always be cut short. It possesses certain advantages over catgut.

In reviewing the field of abdominal surgery we must study shortly the methods and results gained by ovariotomy, removal of the uterine appendages (ovaries, Battey; tubes, Tait), hysterectomy, myotomy, removal of fibroid tumours of the uterus, intraperi-toneal operations on the kidney, liver, spleen, intestinal tract, including stomach, pylorus, duodenum, small and large intestine. Finally, attention should be given to the extraperitoneal operations for sarcoma and disease of the kidney and intestine.

From 1701, the date when Houston of Carluke, Lanarkshire, Ovario-carried out his successful partial extirpation, progress was arrested tomy. for some time, although the Hunters (1780) indicated the practica-bility of the operation. In 1809'Ephraim M'Dowell of Kentucky, inspired by the lectures of John Bell, his teacher in Edinburgh, per-formed ovariotomy, and continuing to operate with success estab-lished the possibility of surgical interference, and was followed in the United States by many others. The cases brought forward by Lizars of Edinburgh were not sufficiently encouraging; the operation met with great opposition; and it was not until Clay, Spencer Wells, Baker Brown, and Keith began work that the pro-cedure was placed on a firm basis and regarded as justifiable. Im-proved methods were introduced, and surgeons vied with one another in obtaining good results, until by the introduction of the antiseptic system of treating wounds this operation, formerly regarded as one of the most grave and anxious in the domain of surgery, has come to be attended with a lower mortality than any other of a major character. We may now briefly outline the mode employed in operating. The room should be well heated, be free from draughts, have a good light, and above all a pure atmosphere. The patient is secured to a firm table and well protected with blankets. An-esthesia having been obtained, the state of the bladder being known, and the urine drawn off if thought necessary, the surgeon purifies the integument with carbolic acid five per cent, solution, attending specially to the region of the umbilicus and pubes, which latter should be shaved. A large perforated waterproof sheet may be spread over and secured to the body, through which the more pro-minent part of the tumid abdomen protruding presents a localized field for manipulation ; this also protects adjoining parts and ob-viates unnecessary exposure. An incision 2 or 3 inches in length in the linea alba and midway between the umbilicus and the sym-physis pubis carries the surgeon down to the interval between the I recti; bleeding points are seized with pressure forceps ; and by a

further use of the knife the subperitoneal fat is exposed, the peri-
toneum divided, and its free edges seized with forceps. The operator
next introduces his finger and with the scissors enlarges the wound
downwards or upwards on the left side of the umbilicus if neces-
sary. The entire hand is then introduced between the parietal
peritoneum and the tumour and swept around so as to ascertain the
condition of affairs, and even to separate gently slight adhesions.
A few sponges are next packed round the exposed tumour surface,
which serve to keep the intestines and omentum out of the way
and to retain any tumour content which may escape during tapping.
With a large trocar, aided perhaps by an exhausting jar, the con-
tents are drawn off, and, as the tumour collapses, its folds may
be caught by forceps and the whole sac gradually pulled outside
the abdomen. The pedicle is clamped by strong forceps; the
tumour is cut off; the stump of the pedicle is carefully ligatured,
the clamping forceps removed, the peritoneum carefully sponged
out, more especially the pouch of Douglas, the ligature cut short,
and the pedicle dropped into the cavity of the abdomen. At this
stage the forceps and sponges are counted, a definite number being
always employed, and, their tale being perfect, the surgeon pro-
ceeds to close the wound. For this purpose his needle traverses
the entire thickness of the pariotes from peritoneum to skin ; the
stitches should be about one-third of an inch apart, and closer
apposition is gained by secondary sutures, which go through the
integument alone. A dressing is now applied, and for the next
few days the patient gets little else than occasional spoonfuls of
hot water and milk, unless brandy be necessary, until she passes
wind, after which time the usual diet is gradually resumed. It is
necessary that the most precise precautions he taken against septic
infection. The sponges are steeped in a five per cent, solution of
carbolic acid, then dipped in boiling water, and squeezed dry
immediately before use. Should the contents of the cyst he too
viscid to run through the trocar, the contents of the sac must be
pulled out with the hand. Adhesions to various organs must be
dealt with by careful separation and ligature. Rents in the peri-
toneum should be stitched up with fine catgut, and some operators
also stitch over the stump of the pedicle, or bury it in a bared
portion of the adjacent broad ligament, so that it may not contract
adhesions. While the great majority of surgeons are at one as
regards the use of antiseptic precautions, they do not agree as to
the use of the spray. Many dispense with it altogether. Some
employ it in the room prior to the operation. A few surgeons also,
without availing themselves of the antiseptic system, appear to
obtain as good, if not better, results than their fellows. It may
also be noted that the antiseptic in use by different operators varies,
and that, while the pedicle is usually ligatured, Keith attaches
great importance to the clamp and cautery introduced by Baker
Brown. The drainage-tube is not now so frequently employed as
formerly. The statistical results show an increasing success in the
case of every surgeon. Spencer Wells tells us that in his first five
years one patient in throe died, in his second and third five years
one in four, in his fourth five years one in five, in 1876-77 one
in ten, since the introduction of antiseptics (complete Listerism),
1878-84, 10'9 per cent,—the last series showing a marked absence
of septic fatality. Keith in 1884 reported a mortality of 9T1 ; for-
merly, when using the spray, he once had a successful consecutive
series of 80. Koeberle up to 1878 had performed 800 operations,
of which 281 had a favourable result. Of 300 patients operated on
by Schroeder up to 1882 258 recovered ; in the last hundred cases
there were only 7 deaths. Other figures are—Knowsly Thornton,
423 cases, 40 deaths ; Tait, 405 cases, 33 deaths, and in 1885 (in-
cluding parovarian cysts) 139 cases, no deaths ; Olshausen (1885),
293 cases, 27 deaths (in the last hundred only 4 deaths).
Removal Removal of the uterine appendages, the ovaries and Fallopian
ofuterine tubes, is performed for three distinct conditions—(1) for disease,
appen- when the tubes are the seat of inflammatory changes and dis-
dages. tended, or when the ovaries are the seat of cystic and cirrhotic
changes ; (2) for fibroid tumours, in which case by operating we
hasten the menopause and bring about involution ; (3) in cases
where dysmenorrhcea is wearing out and rendering useless the
life of the patient, and where less severe treatment is ineffectual.
Oophorectomy, by which we mean removal of the ovaries only,
was introduced by Battey of Georgia in 1872. It is now replaced
by the more extensive procedure of Lawson Tait, sapingo-oophor-
v eetonry. The operation is sometimes followed by loss of sexual
feeling and has been said to unsex the patient, hence strong objections have been urged against it. The patient and friends should clearly understand the object and results likely to be gained. According to Angus Macdonald, "as soon as we are certain that the ovaries or tubes are distinctly diseased and are not likely to yield to our ordinary methods of treatment . . . we are hound to at least inform our patient of the possibility of relieving her by opera-tion. The operation presents greater difficulties and is associated with a higher mortality than ovariotomy." The greatest care must be taken in making the initial incision for fear of wounding the boweL The organs are not uncommonly deeply placed and have contracted adhesions. Every trace of ovarian tissue should be removed along with the tubes and the ligatures must be carried close up to the uterus. The stitches should be placed closer, since the tendency to hernia is greater.

In eases of fibroid tumour—myoma—the surgeon must be largely Hyster-guided by the condition of the patient and the new growth as to eetomy. whether removal of the uterine appendages is sufficient. If it is not and the patient is in such danger that the next period threatens life, he had better proceed to hysterectomy or entire removal of the uterus and appendages. When we consider the circumstances under which this operation is performed, the weakly anaemic state of the patient, the size of the tumour, and the rapidity with which procedure should be conducted, we must regard hysterectomy as one of the gravest in the domain of surgery. There is, moreover, a special danger which does not obtain in ovariotomy, —the risk of septic poisoning. Since we cut into the canal of the uterus, it is obvious that we open into a septic cavity, and it is impossible merely to ligature and drop the pedicle, since by doing so we should court failure. The surgeon, having made a way into the peritoneum, seizes and ligatures adhesions, projects the tumour through the wound, clamps the pedicle (cervix uteri), removes the tumour and uterus, and closes the wound, leaving the clamped pedicle protrud-ing. It is advisable to scoop out the septic central canal of the pedicle and carefully to pare away surplus tissue, and as dressing to have a plentiful supply of some potent non-irritating antiseptic in contact with the stump. If we take care that the septic focus is removed without coming in contact with its surroundings, if we keep the stump aseptic and dry, there will be little fear of septic fluid trickling down the side of the pedicle and causing septus, peritonitis, or blood-poisoning. Attempts have been made, by care-ful disinfection of the stump, paring its centre, careful ligature, and stitching its raw surfaces together, to treat the pedicle by dropping it into the abdomen as in ovariotomy, but as yet with no marked success. The results of hysterectomy in the hands of Keith (33 cases, 3 deaths, in 1885) stand unrivalled. Similar principles guide the performance of cesarean section and Porro's operation.

Affections of the liver and gall-bladder have also been treated Removal by laparotomy. In the latter case an incision is made over the of gall-swelling, and the gall-bladder, having been exposed, may be removed bladder; or explored, gall-stones cleared out, the walls stitched to the sides of the abdominal wound, and a drainage-tube inserted as occasion requires. The spleen has also been attacked. In removal of the spleen; entire organ special care must be taken that none of the larger veins give way during manipulation. Most careful ligation and sub-division of the pedicle is requisite. In recent years the surgery of the kidney has made gigantic strides. There* are three modes of kidney; reaching the organ, each of proportionate value according to the nature of the case. (1) From the lumbar region. In this way we may open abscesses, remove calculi, and even extirpate if the kidney be not enlarged. Increased room may be obtained by re-moving the twelfth rib. By this method we gain sufficient and dependent drainage and we need not open the peritoneum. (2) As in ordinary laparotomy, making an incision in the middle line. This admits of our examining both organs and to a large extent determining the condition of each. We get free access and can more readily treat the pedicle of vessels and the ureter. We open into the peritoneal cavity and again divide the peritoneum ; but our incisions are readily closed and we no longer dread interfering with this huge lymph-sac. For tumours of the kidney this method is clearly indicated. (3) Langenbuch has proposed making an incision along the outer border of the rectus, which is said to present advantages in certain cases.
Since the advance of ovariotomy the possibility of removal of portions portions of the intestinal tract with a subsequent suture of the of intes-divided ends has been repeatedly demonstrated, and thus resections tinal for disease of the pylorus and bowel have been successfully performed, tract. In cases of gunshot wound, laparotomy, arrest of haemorrhage, careful cleansing of the peritoneum, and suture of the wounded gut is now the established practice. Bull of New York reports a recovery in a case where seven wounds in the gut were sutured. All laparo-tomies are founded on the type of ovariotomy ; success depends on the fact that two opposed serous surfaces rapidly unite, and this fact must ever be borne in mind when we tear or injure the bowel and its coverings, or unite them. Sepsis is the main disaster likely to attend our interference, but with the means at our disposal, washing out the peritoneum if necessary, we should be able to obviate this.
In regard to operations on the abdominal organs in which we do not interfere with the peritoneum it is sufficient to note that from the lumbar region we can reach the colon, where it is uncovered by serous membrane, the kidney, and retroperitoneal tumours. (F. M. C.)

4.' Deformities.

(1) For club-foot, see vol. vi. p. 42.
(2) During the last few years, in consequence of the safety with

Knock- which bones may be divided, other deformities, such as knock-knee knee, &e. or genu valgum and bow-leg or genu varum, have been remedied by operation. Drs Macewen of Glasgow, Ogston of Aberdeen, Schede of Hamburg, and the present writer have been working at this subject and have devised, more especially in knock-knee, various methods of remedying the deformity. Operations are only justifiable when the deformity has become chronic. During the advancing stage, when the deformity is getting worse, when the bones are still cartilaginous and plastic, the evil can be remedied by mechanical means. This statement may be best illustrated by a short consideration of the development of the lower limbs and the changes which normally take place. At birth all children are more or less bandy-legged. The child lies on its nurse's knee with the soles of the feet facing one another ; the tibiae and femora are curved outwards ; and, if the limbs are extended, although the ankles are in contact, there is a distinct space between, the knee joints. During the first year of life a gradual change takes place. The knee joints approach one another ; the femora slope downwards and inwards towards the knee joints ; the tibiae become straight; and the sole of the foot faces almost directly downwards. While these changes are occurring, the bones, which at first consist princi-pally of cartilage, are gradually becoming ossified, and in a normal child by the time it begins to walk the lower limbs are prepared, both by their general direction and by the rigidity of the bones which form them, to support the weight of the body. If, how-ever, the child attempts either as the result of imitation or from encouragement to walk before the normal bandy condition has passed off, the result will necessarily be either an arrest in the development of the limbs or an increase of the bandy condition. If the child is weakly, either rachitic or suffering from any ailment which prevents the due ossification of the bones, or is improperly fed, the bandy condition may remain persistent. As a rule, how-ever, in children that are precocious as regards walking, if proper care is taken the bandy condition will disappear without any special treatment. In a healthy child who does not attempt to walk until the limbs are prepared to support the weight of the body, no further abnormal change takes place. But in a weakly child in whom the development already described has occurred, in whom the limbs as regards their general direction are prepared for the support of the body, but in whom the bones forming the limbs are not sufficiently ossified, as in the rachitic child, the shafts of the femora above the knee and the shafts of the tibiae below the knee bend forwards; at the same time a change takes place at the knee joint,—the condition called knock-knee. In the normal limbs, the tibiae being vertical and parallel, and the distance between the upper extremities of the femora being greater than that between their lower extremities, the femora necessarily slope inwards towards the middle line, and there is therefore in every properly developed person an angle at the knee joint. If at this stage the bones are sufficiently rigid to bear the weight of the patient, no further change takes place; but, if the limbs give way and are not sufficiently strong, the normal angle at the knee joint increases and the internal iateral ligament of the knee joint becomes stretched,—the result being knock-knee. The condition may be arrested in its earliest stage by an improve-ment in the general health of the child ; but, if no such improve-ment takes place, and if the child is allowed to walk, then definite changes occur in the bones which form the knee joint. These changes are the direct outcome of a general law, namely, that diminished pressure results in increased growth, increased pressure in diminished growth. The best example of the former principle is the rapid growth that takes place in a child that is confined to bed during a prolonged illness. The distorted, stunted, shortened, and fashionable foot of the Chinese lady is an example of the latter. In the knee joint there is diminished pressure between the internal condyle of the femur and the inner condyle surface of the tibia; there is increased pressure between the external condyle of the femur and the outer condyle surface of the tibia. The result is an increased growth of the internal and a diminished growth of the external condyles; the knock-kneed condition is intensified, and will go on as long as the primary cause is at work, getting worse and worse, and will only cease when the bones become fully developed. As long as the disease is getting worse, the application of a rigid splint to the outer side of the limb fixed at the foot and at the upper part of the thigh, and the arrangement of an elastic bandage so as to draw the limb towards the splint, the person being kept in the horizontal posture, will cause a diminution in the pres-sure on the external condyles followed by their increased growth, and by an increased pressure on the internal condyles followed by a diminished growth. This effect may be obtained by applying a weight to the limb ; and by mechanical means founded on this general law cases of knock-knee that are getting worse can be im-proved. At first there is an arrest in the abnormality, which is soon followed by improvement. The different methods that.have been recommended for division of the bones are only necessary in those cases in which they have become permanently distorted.
(3) Lateral curvature of the spine is a deformity which occurs Spinal
during the developing period of life before the bodies of the verte- eurva-
brœ are fully ossified. In young people who are growing rapidly, ture.
and whose muscular system is weak, any bad habit, as, for example,
that of standing and throwing the weight of the body constantly
on one leg, gives rise to a drooping of the pelvis on one side ; or,
if, "when writing at a desk, they are allowed to sit in a twisted
position, a lateral curvature of the spine takes place. By constant
indulgence in these bad habits the cartilaginous spinal column gets
set in an abnormal direction. In the concavity of the curve there
is increased pressure and necessarily diminished growth, in the con-
vexity of the curve diminished pressure with increased growth.
The patient's friends will probably notice first the right scapula
being pushed backwards by the underlying ribs, which from their
close attachment to the dorsal vertebrae participate in a rotatory
movement occurring in the vertebrae themselves, and, unless means
are taken to alter the abnormal distribution of pressure, the con-
dition will become worse and worse, until complete ossification
checks the progress of the deformity. The commonest curvature
is one in which there is a dorsal convexity towards the right, with
the right shoulder higher than the left. Compensatory curves in
the opposite direction form in the lumbar and cervical regions.
Along with the lateral curvation a rotation of the bodies of the
vertebrae towards the convexity of the curve takes place ; their
spinous processes necessarily turn towards the concavity of the curve.
Since the line of the spinous processes of the vertebrae can be easily
traced through the skin, their deviation may mislead the superficial
observer as to the true direction in which curvature has taken place.
As the lateral curvation occurs the articular facets along the line
of the concavity are pressed together, the line of these facets being
posterior to the bodies of the vertebrae and their intervening elastic
intervertebral disks. The result of this is that the vertebral
column as a whole cannot fly away towards the convexity. The
anterior parts of the bodies, being farthest away from the fixed point,
are least restrained from movement, and they pass away to a greater
extent than the posterior parts. The result is a rotation of each
vertebra in the direction indicated. To counteract this deformity
in the earliest stages, the patient (generally a girl) should be en-
couraged to walk about with a book on her head, to retain which
in position she must necessarily keep perfectly erect. Muscular
exercises, to strengthen the muscles of the back, ought to be en-
joined and superintended by the surgeon. During the intervals of
rest she should lie upon her back on a firm board, and should care-
fully avoid taking any exercise which gives rise to weariness of the
muscles ; for, whenever the muscles become wearied, she will at-
tempt to take up a position which throws the strain off them on to
her ligamentous and bony structures. One of the best exercises is
to lay the patient on her face, fix her feet, and encourage her to
raise herself by using the muscles of the back. When the deformity
becomes more marked the use of the trapeze should be prescribed.
Hanging with her arms upon the trapeze, the weight of the lower
limbs and pelvis will tend to straighten the spine as a whole, neces-
sarily diminishing the increased pressure upon the cartilaginous
bodies of the vertebrae towards the concavity, and increasing the
pressure between the sides of the bodies towards the convexity. The
tendency to rotation must be counteracted in another way. The
pelvis being fixed, elastic bands attached to fixed points, one in
front of the patient towards her left side, another behind her to-
wards her right side, are to be grasped by her right and left hands
respectively, the right arm passing in front of her body, the left
arm behind it. When the patient stretches both hands simul-
taneously there will be an untwisting of the spine in a direction
opposite to the abnormal rotation. In this description, the com-
mon curvature—namely, of the dorsal region towards the right—_
has been taken as a typical example to illustrate the treatment.
When the dorsal curve is in the opposite direction, the untwisting
of the curve must necessarily be in the opposite direction also.
During the intervals of active treatment the patient must wear a
rigid support, which in itself has no direct curative action, but will
materally assist the treatment by preventing the good result obtained
by the muscular exercises from being nullified. (J. C. )



Footnotes

679-1 The gauze dressing consists of thin gauze which has been soaked in a mixture of carbolic acid (1 part), resin (5 parts), and paraffin (7 parts). The object of the paraffin is to prevent the gauze sticking to the skin. The resin retains the carbolic acid and prevents evaporation at the ordinary temperature; at the temperature of the body, however, a certain quantity of the carbolic acid is constantly being given off, and in this way the part operated on is enveloped in a vapour of carbolic acid. This antiseptic vapour persists as long as there is any carbolic acid in the gauze. A gauze dressing is not reliable for more than a week ; by that time the carbolic acid in the gauze is dissipated aud the dressing requires to be renewed.

680-1 John Hunter defines '' vitality " as the power which resists putre-faction.

681-1 For their classification, as yet very imperfect, consult Ziegler's Pathological Anatomy (trans, by Macalister, London, 1883-84).


The literature of abdominal surgery is very extensive. The most complete lists will ba found in Olshausen's " Die Krankheiten der Ovarien," in JHs deutsche Chirurgie, 1880, and in Hart and Barbour's Manual of Gynecology. Compare PATHOLOGY, vol. xviii. p. 367 sq.