IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 11.25 !^ i^ 112.0 6" 18 U ill 1.6 riiOuj^dpiuC Sciences Corporation iv ^ #^ :\ \ O^ Q" .A <^,.>> 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 873-4503 '% ■ O" ' CIHM/ICMH Microfiche Series. CIHM/ICMH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques > Technical and Bibliographiu Notes/Notes techniques et bibliographiques The Institute has attempted to obtain the best oriyinal copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the images in the reproduction, or which may significantly change the usual method of filming, are checked below. □ Coloured covers/ Couverture de couleur r~n Covers damaged/ D D D n Couverture endommagde Covers restored and/or laminated/ Couverture retitaurie et/ou pelliculie □ Cover title missing/ Le titre de couverture manque I I Coloured maps/ Cartes giographiques en couleur □ Coloured ink (i.e. other than blue or black)/ Encra de couleur (i.e. autre que bleue ou noire) □ Coloured plates and/or illustrations/ Pli Planches et/ou illustrations en couleur Bound with other material/ ReM avec d'autres documents Tight binding may cause shadows or distortion along interior margin/ La re liure serr^e pei T1NUED"). or the symbol ▼ Imeening "EIMO"), whichever appliae. Un dee symboles suivants apparaitra sur la demiAre imege de cheque microfiche, seion caa: le symbols —*> signifie "A SUIVRE ", le symboie V signifie "FIIM". Meps, platee. charts, etc., mey be filmed at different reduction ratioa. Thoaa too lerge to be entirely included in one exposure are filmed beginning in the upper left hend comer, left to right and top to bottom, aa many framee aa required. The following diagrama illuatrate the method: Lee cartee, planches, tableaux, etc.. peuvent dtre filmie d dee taux de rMuction diffirents. Lorsque le document eet trop grand pour dtra reproduit en un seul clichA. ii est fiim^ i partir de I'angle supArieur gauche, de gauche d droite. et de liaut an baa. an pranant le nombre d'Imegea nteassaire. Las diagrammes suivants illustrent le m^thode. 1 2 3 1 2 3 4 5 6 1 1 ! / REPOET ON F BY FRANCIS J. SHEPHERD, M.D.J EEPOET ON SUEGEEY. BY FRANCIS J. SHEPHERD, M.D., CM., M.R.C.8., Eno. J ■Mi|i^M*tfMI**Btkf«*'«>4H>. .*- .V: t ^V '/ ,^' Eaprinted from iJie Canadian Journal of Mkdioai, Sciknce, September, 1882. EEPOKT ON SURGEKY. {Read be/ore the Canada Medical Association, Sept., 1882.) By FRANCIS J, SHEPHERD, M.D , CM. M.R.C.S., Eng., DemoMtrator of Anatomy, and Lecturer on Operative and Minor Surgrery, UcOill Unlvenity; SurRcon to Out-Patient Department, Montreal General Hospital. . \ f Mr. President and Gentlemen, — 1 do not propose in this report to give an account of aU the advances and discoveries made in surgery during the last twelve months, because I know from experience how tiresome and uninter- esting such a recital of facts is. My intention is to touch on some of the more important and interesting points, so that they may serve as texts which may be elaborated in the discus- sion I hope will be aroused. The subjects I shall glance at will be as follows :— (1) Treat- ment of Wounds ; (2) Cause of Inflammation ; (3) Sponge Grafting and Bone Transplantation ; (4) Surgery of the Kidney ; (6) Treatment of Club-foot; (6) Surgery of the Joints. The list looks a formidable one, but remember that I only intend to furnish the texts, the sermons belonging to which I hope you yourselves will preach. The Treatment of Wounds. — Within the last few years this subject has more than ever occu- pied the attention of surgeons, and has caused many acrimonious discussions. Old methods of treatment have been wholly discarded and new methods introduced, of greater or less value. Some of these are being constantly improved and modified, others flourish for a time, but when the sun of experience is <;umed on them, like the seeds which fell on stony ground, they are scorched and wither away. At the present time, all methods, however much they differ in detail, aim at keeping wounds aseptic, and are in fact antiseptic methods of treatment. Listerism is only a phase of antisepticism, and does not differ as much from other methods as one would at first - sight imagine. The great difference consists in the more gorgeous ritual and its obscuration by the clouds of incense (in the form of carbolic spray) which ascend heavenward as a pro- pitiatory sacrifice to the great ^sculapius. The fundamental principles are, however, the same, viz : cleanlir.ess, asepticity, rest, sup- port, and the accurate adjustment of cut sur- faces; and to Mr. Lister principally we owe the universal recognition of the truth of these principles. He, in fact, by dwelling on their importance and evidencing their truth by the success of his own practice, has revolutionized the surgical treatment of wounds. He has shown that suppuration and the septic condi- tion it leads to may be prevented. He has taught surgeons the necessity of thoroughly cleansing and disinfecting their instruments and hands before operation. At the Interna- tional Congress held in London, the subject of the treatment of wounds was one of the most important that engaged the attention of the surgical section. From the papers read and the discussion which followed their reading, it .x that- *U£. v.«i:-^ ;_ xu- 1 -';-,. ^H spray was on the wane, and that it was desir- able that some form of dressing less compli- cated than Listerism should be employed. Mr. Lister himself spoke in qualified terms of the spray, and hoped at some future time to be Jdport on /Surgery^ able to say "fort tnit dem Spray." Profemor Esmarch's wonderful statiatics aided greatly In confirming the confidence of Burgeons in rest, support, and infrequent dressings. Much evidence whs ottered, and many opinions were given which supported the views of Mr. Sampson Oarogee as to a dry form of antiseptic dressing. Since the Congress the dry method of treating wounds with infrequent dressings has made wonderful strides, and bids fair to supplant Listerkm as a form of antiseptic treatment. Under dry dressings, wounds heal much more rapidly than under moist warmth, which encourages putrefaction. Iodoform dressings have been most generally used in Germany, but so recklessly that many cases of poisoning from it have been recorded. A» much as 7 to 8 ounces have been stuffed into ab- scesses and excised j oints at one time. No case of poisoning has been reported from Germany where less than 3 drachms was used. Wher- ever possible I have employed the dry form of dressing, and I think with success. My method of dressing a fresh wound (for which I claim no originality) is as follows : After all bleeding has stopped, and the wound has been accurately closed by cat-gut ligatures, and when necessary by wire ones in addition, I sprinkle over the wound a little iodoform, cover this with a strip of oil silk (to prevent adherence of the wool), and then over all place a pad of boracic cotton. ThU is kept in place by an accurately adjusted gauze bandage, which must be evenly and firmly applied, so as to get the amount o( elastic pressure required. If neces- sary, as in a limb, a paste-board or other light splint (well padded) is applied. If the parts can be accurately adjusted by pressure, drainage is not required. The wound, if the patient complains of no discomfort, should not be disturbed for a week or more. When the dressing is taken down, the wound h generally found to be nearly or quite healed. In foul ulcers, this method I have found supe- rior to every other. In some cases of accident, where thn Mcuma ip ir^t- «~ «- . u •_ • , .„ ,5j„„^ „j oo uiuuxi injured as to be beyond repair, I have generally employed the moist form of dressing till the slough has separated. Of late I have been using a solu- tion of boroglyceride, as recommended by Mr. Barwell. This antiseptic, as far as my experi- ence goes, is superior to carbolic acid. It has no odoiir, and is perfectly innocuous. With regard to Inflammation, and ita oon- nection with septic organisms. The theory that you are no doubt most familiar with is that inflammation is due to (he introduction of at- mospheric germs into damaged tissue, and that if this introduction be prevented, the wound heals without inflammation. Prof. Hueter, Mr. Lister, Mr. Watson Oheyne, and others] have been the most able and efficient advocates of this view. There is, however, another, and I think a more probable explanation of the origin and spread of inflammation, of which Dr. Burdon Sanderson has lately in his Luin- leian Lectures given a clear and convincing account, viz., that "inflammation is the physio- logical effect of traumatism"; that the exu- dates of a normal inflammation are not infec- tive; that no inflammation producing organisms exist in the atmosphere ; that whenever inflam- mation becomes infective it owes that property to chemical change in the exudation liquid, which, in absence of any other better explana- tion, we attribute to the presence of septic organisms or bacteria or, in other wordp, exudative fluids which are infective owe that property to the exudative soil in which the germs grow, and that atmospheric germs are not per se a source of danger. Dr. San- derson says these germs are not so much mischief-makers as mischief- spreaders— they have the power of developing what he calls a phlogogenic infection, and of conveying it to all parts of the body. I do not propose to discuss this question, but merely place it before you as a subject for discussion, in its bearing on antiseptic surgery. Before passing on to another subject, I should like to draw your attention to some recent experiments by Dr. D. J. Hamilton on Sponge Grafting, and their bearing on surgery. Dr. Hamilton some years ago showed that the vessels of a granulating surface are not newly formed, but are simply the superficial capillaries of the part that have become displaced : that the granulation loops are thrown I'p by vhe propelling action of the heart. Whilst pursuing these investigations, Mr. Hamilton was struck with the bimilarity Report on Surgery. of the prooeM of irasonlarization, as seen on a granulating surface, and that which occurs when blood-clot or fibrinous exudation is re- placed by vascular ciofatrioial tissue. He states that blood-clot or (ibrinonB lymph plays merely a mechanical and passive part in any situation, and that vascularization is n jt due to the for- mation of new vessels, but rather to a dis- placement and pushing inwards of the blood- vessels of the aui rounding tissues. He looks upon blood-clot and fibrinous exudation as so much dead matter, which aflPords merely a framework f^.r the capillaries to ramify in, "and proves that it is so by employing sponge to replace it. This sponge is prepared in a spe- cial way, and when placed on old ulcers he succeeded in organizing it — or rather filling its interstices with blood-vessels and cicatricial tis- sue, the sponge in the meantime disappearing by absorption. Many other experiments were made which fully proved his theory. Dr. Hamilton noted a significant phenomenon, supporting the theory that blood-vessels were pushed into the sponge in loops, when the con- vexity of a loop came in contact with the sponge framework, instead of one of its pores, a curvature formed on the vessel at the oppo- sing point, and on each side of the obstacle there was pushed a secondary loop similar to that from which both had arisen. These blood- vessels, according to Mr. H., bear with them great numbers of the actively proliferating con nective tissue corpuscles from neighboring con- nective tissue, and these, and not the leucocytes, are the tissue-forming cells. Sponge Grafting, he says, is excellently suited for growing new tissue where that is insufficient to cover a part. Instead of sponge, charcoal or calcined bone might be employed in certain oases, as, for instance, where the formation of new bone is needed. The Trantplantation o/Bone has been success- fully accomplished both by Dr. MacEwen, of Glasgow, and Mr. McNamara, of Westminster Hospital, London. They had been pursuing their investigations on this subject at the same time, unknown to one another. Dr. MacEwen placed his case first before the public. He re- made a humerus which had been destroyed by necroBia, by placing small fragments of bone (removed from patients with curved tibin) in a groove made in the soft tissues in the position of the humerus. Mr. McNamara suocemfully replaced a tibia which had become deficient from acute necrosia He used portions of bone from an amputated mei.\tarsus. The necessity for transplanting bone is necessarily rare, as nature is so skilful in the repair of bone, that the interference of the surgeon is seldom needed. These experiments carry out Mr. Hamilton's theory of organization, and are in- teresting from a surgical point of view. The surgeon looks upon no organ or region now as sacred. Operations are at present daily performed successfully which, if even suggested a few years ago, would have been looked upon as absurd. The lung has been partially excised, the liver has been cut into, and parts of it removed successfully. The whole stomach has been excised, and the oesophagus stitched to the duodenum, and many feet of intestines have been taken away, and the cut ends stitched together, patients making good recoveries. The renewed attempts at removal of the spleen have not been so successful as of old ; the whole uterus has been excised, even when pregnant, and ihe patient has sur- vived, but this now belongs to the realm of gynsBcology. The surgery of the organ which I am going to notice has, as yet, escaped the upward tendency of the gyneecolc^ist, but how long it will remain in the domain of pure sur- gery I know not, as already one of its depen- dencies (the bladder) has been annexed in the female. The Swrgery of the Kidney h is greatly en- gaged the attention of surgeons during the last twelve months. At the International Congress it was the subject of several papers, and caused much interesting discussion. Since then it has occupied considerable space in the Medical Journals, and the operations of nephro-litho- tomy; nephrotomy, and nephrectomy have be- come recognized operations. It has been estab- lished beyond doubt that nephro-lithotomy is a most successful operation in properly selected cases, viz., where the stone is of moderate size and single, and tie kidney has not become dis- organized. It is a most scientific procedure to perform this operation where stone has been Report on Sttrgery. certainly diagnosed by needle exploration, or whore the pain and other aymptouiB lead one to l)elieve there is a stone present. If left, the stone is certain to disorganize the kidney, cause much suffering, and probably death. The operation of incising the kidney {nephrotomy) has not proved a dangerous one, and it has been frequently demonstrated that the kidney can be easily explored through a lumliar in- cision, and even out into with great safety. In cases of strumous or calnulous pyelitis, the sac- culated kidney can be drained through a wound in the loin and the patient freed from the danger and pain of retained matter. Nephro- tomy, as an operation, is merely palliative, and, nephrectomy, or removal of the kidney, is a much more formidable operation than the fore* going. The dangors are greater, and many cases have been followed by suppression of urine. It has also proved fatal from hemor- rhage, and wounds of neighbouring organs, as lung and pleurae. As yet it has not been positively detemined in what cases, or at what period, it should be perfoi med. It has been ' for tumour, cancerous diseases, and •'• nous and calculous pyelitis. It is a \>u tion whether before nephrectomy is pei- formed, a preliminary nephrotomy should not be tried. Now the loin is the most favourable position for nephrotomy and, perhaps, the most difficult incision for nephrectomy, so this would be an objection. Some hold that if a prelim- inary nephrotomy is performed, it much in- creases the difficulty of a subsequent nephrec- tomy. Again, it is important, in considering the advisability of performing nephrectomy, to find out whether the pyflitis is confined to one kidney, or, rather, whether the other kidney is healthy. Strumous pyelitis is rarely confined to one kidney, and, therefore, excision of the kidney must be a defective operation, as the pyelitis is only a small part of a general dis- ease. Th. Gluck has lately suggested a method of pointing out which kidney is diseased. He advises cutting down on the ureter of the sup- posed morbid kidney, and obliterating its lumen with ligature or clamp. A solution of some salt, rapidly excreted by the kidneys 18 then injected subcutaneously, and its presence \ after a short time ascertained in the urine by means of tests ; if none is found, then the other kidney is diseased, and the ligature should be removed and the wound sewed up ; but if found readily, the operation of excision is proceeded with. These are some of the difliculties in the way which make one hesitate to perform nephrec- tomy. Having, however, decided on the oper- ation, which is the best incision, through the loin or abdomen? Certainly the abdominal incision gives the operator more room, and the surgeon sees what he is doing. Kemoval through an incision in the loin is very difficult, especially the ligaturing of the vessels entering the jwlfis of the kidney, besides, in some people, the distance between the last rib and crest of the ilium is very short ; in these cases, of course, the, 12th rib has to be excised, or a Y incision made, both of which procedures increase the risk of the operation. The only objection to the abdominal incision is that two layers of peritoneum are wounded ; but now-a- days we are not so fearful of wounding that structure as formerly. I leave the further discussion to you as to when and how we should I)erform nephrectomy. Treatment of Club-foot. — As long as these deformities occur, so long will the remedyirg of them engage the attention of the surgeon. Ordinary simple cases may be successfully treated by bandaging and manipulating, or the use of elastic springs. More severe cases by tenotomy, and afterwards with the proper ap- paratus, plaster-of-Paris, splints,