CHAPTER LVII

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AMPUTATIONS 1023

GENERAL SURGERY.

INTRODUCTION.

An ultimate analysis of the primary causes of disease, excluding traumatisms, will permit their reduction to one or the other of the following categories: _nutritional_ (functional) and _parasitic_. These may co-exist, in which case each tends to modify the other more or less, usually unpleasantly, or either may precede and perhaps pave the way for the other. In general, it may be said that parasitism perverts nutrition, locally or generally, and, _per contra_, that perverted nutrition often prepares the way for parasitic infection, so that even between these primary causes there may occur all possible combinations.

With traumatisms surgery alone is mainly concerned, but its conceded scope is now widened to include an ever-increasing number of morbid conditions, which, in time past, were treated medicinally--or not at all. Thus it has come to pass that it is no longer possible to make an abrupt distinction between medicine and surgery, nor even briefly to define the words “surgery” and “surgeon,” nor yet to ascribe to either the physician or the surgeon his exact functions as such. In centuries past physicians were exceedingly jealous of their vested rights, and with propriety, when the only surgeons were uneducated barbers. But about one hundred years ago conditions were materially altered for the better, and surgery, liberated from its medieval environment, and from the restrictions imposed by the clergy, rapidly developed into both a science and an art, while the surgeon came to take that position in society to which his increasing attainments entitled him. During the past thirty years surgery, thanks to earnest workers in the surgical laboratories of the world, has made progress scarcely equalled by the science of electricity, and the impossibilities of yesterday have become the routine of today.

Thus has come about the earlier separation, and now, in some respects at least, the closer appreciation of the respective scope and functions of the physician and the surgeon. Between them lies yet what has been felicitously called the “borderland,” where they meet on common ground, too often as rivals and not often enough as co-workers. Nowhere do comprehensive knowledge, wide experience, and trained judgment appear to better advantage, nor lead to better results, than when exhibited where co-operation in these respects is most hearty. Someone has most happily said that “the surgeon is a physician who knows how to use his hands,” yet to regard a course in surgery as one in manual training would be a most lamentable conception of its purposes. Rather is it to be regarded as a superstructure, to be built upon a thorough familiarity with anatomy, physiology, pathology, and therapeutics. In fact, the better general practitioner a man is, the better surgeon may he thereby become, providing he possess the other necessary attributes. John Hunter took this view, but too many since his day have forgotten or never realized it.

In the pages which follow it has been impossible to do more than epitomize our present-day knowledge of surgery, an early disavowal which is intended to save too frequent repetition of the advice to consult, as needed, other larger and more specialized works. The attempt here has been rather to build up a framework upon which the student and the investigator may build with such other material as they may later select from the quarries which are accessible to them. Hence it has been impossible to describe or even mention all the operations which have been devised to meet various indications. Preference has therefore been given to those which have best served the author in his personal experience.

Because of the numerous interrelations between surgery and internal medicine, so called, I have not hesitated to insert paragraphs and even whole chapters on subjects hitherto omitted from the later works on surgery. To teach a student how to recognize nasopharyngeal adenoids, to appreciate the widespread harm they may cause and how to cope with them, and at the same time to leave him quite unfamiliar with their too frequent relation to the status lymphaticus and its dangers, and to omit in such a work all reference to the latter, is to put knowledge and instruments into his possession without teaching him how rightly to employ them. A case of exophthalmic goitre affords another equally apt illustration, as being one in which the physician and the surgeon should heartily co-operate.

The surgeon and the physician have drifted too far apart. It is time that they met again in the presence of the pathologist. Such a group, when properly constituted, forms an almost invincible triumvirate.

It has been said that “the resources of surgery are rarely successful when practised on the dying.” Throughout these pages the attempt has been made to impress the fact that delay, in many of the borderland cases, is dangerous, and, often fatal, and that it is not just to charge to surgery the blame for such a result due to the physician’s dilatoriness.

It may lead to a better understanding of the teaching contained in the following pages if it is here made clear just what is understood by the suffix “_itis_” in medical terminology. The old tendency was to regard all morbid conditions as expressions of inflammation in some of its protean manifestations. The attempt has been made in this work to distinguish as clearly as possible between _inflammation, as an expression of infection_, and the vascular, nutritional, and other changes which may be brought about by perverted nutrition without necessary participation of parasites. To describe “ostitis,” for example, as “inflammation of bone,” is to revert to an obsolete definition. Let us, then, always translate the termination “itis” as implying an _affection_, not necessarily an inflammation, of the structure named in the word to which it is affixed. With this conception of the word or the term there can be no contradiction in its use under various conditions, and one does not necessarily commit himself, by using it, to any definite view concerning the pathology of the affection which is thereby implied.

With regard to one other feature there has been also a departure from previous nomenclature. The term “lymph glands” or “lymphatic glands” has always seemed objectionable, because, although they belong to the lymphatic system, they are in no sense glands, having no ducts, and no distinct secretion to be discharged through passageways. Whether in any sense they are to be regarded as furnishing an “internal secretion” is not the question here, their most obvious function being to act as filters. Throughout the work, then, the term “lymph gland” has been carefully excluded and the more accurate and far preferable term “lymph node” has been substituted. This seems to be a suitable place to explain the substitution and the reason therefor.

## PART I.

SURGICAL PATHOLOGY.

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