BMJ (Clinical Research Edition)
MEDICAL JOURNAL. many great minds, of a swarm of little ones; but even these produce some good. We cannot afford to lose one opportunity, one idea-no, not even one suggestion. Doctrine anid practice, brain and hands, must pari passu be cultivated. The mind, like the stomach, best digests a varied meal. No good quality can be left without exercise; the best land will not bear fruit unless furrowe(d by the plough and strewn with seed. Above all, honesty requiires to be treasured. All students and
... d. All students and observers are not honest. It shall be my aim to endeavour to set you an example of impartial inquiry and candid statement. Ours is to be no one-sided picture-no partial truth. What is wanted is the truth, the whole truth, and nothing but the truth. Witlh these principles, it is reasonable to hope that we shall be permitted to confirm established truths, to eliminate many elrors now prevalent, to establish propositions yet unlknown, and comprehensively to take a part in the development of a sounid medical philosophy-a rather big word, but a very simple one. Nature is always philosophical; a universal sense pervades it. We have but to follow, to interrogate, and learna work of ease, though of toil. It necessitates only one sacrifice -vanity: it requires only a just conception of truth, a firm resolve only to be satisfied with its attainment. SURGERY. THIE OBJECTS OF SUBCUTANEOUS SURGERY. MR. I\IJLIAM ADAMS selected, as the subject of the Oration wlich he was appointed to deliver at the last anniversary meetingr of the MlUedical Society of London, a sketch of the principles and practice of orthopedic surgery. From that instructive oration, which has lately been publisbed, we make a few extracts. Mr. Adams expresses his intention to be, to showv the practical application of the followinig law regarding the reparative process, enuinciated bv Jolhn Hunter in his Treatise on the Blood, Inflamnmation, and Gunshot WJ'ounlds, in the following words T The injjuries done to sound parts I shall divide into two sorts, according to the effects of the accident. The first kind consists of those in wlvich the injured parts do not communicate externally, as concussions of the whole body or of particular parts, strainis, bruises, and simple fractures, either of bone or ten(lon, wvhich form a large division. The second consists of those whichl have an external conimtmnication, comprelhending wounids of all kinds, and compound fractures. Bruises which lhave destroyed the life of the part may be considered as a third division, partaking, at the beginning, of the nature of the first, but finally terminating like the second. The injuries of the first divisioni, in which the parts do not communicate externally, seldom inflaine, wvhile those of the second commonly botlh intlarne andl suppurate." After illustrating this subject, Mir. Adams goes on to classify the cases in which subcutaneous operations are indicated. CLASS I. The operations in the first class are performed subcutancously, wvith the sole object of atvoiding the inflammation and its consequences, wlicih would necessarily ensue if they were perfornmed by open wounds. Operations are generally performed with tllis view in important organs or regions in which inflammniation would either be dangerous to the lite of the individual, or involvNe loss of function of the part. In this class a very large number of subcutaneous operations are included, of which tlhe following are the principal examples. 1. TIhe remtioval of loose cartilages from the joints by suibcutaneous incision, as first performed by Mlons. Go)yrand, of Aix. There ecan be no doubt that the subcutaneous method, by which this operation is at present performed, deservedly ranks amongst the greatest improvements of modern suirgery, and is the only procedure consistent with the safety of the limb or of the patienit. 2. The division of al-tic tlar-ligmaments tofacilitate the reduction of old dislocations and the remoral of deformities. These operations have been frequently performed, and prove that the joints may be opened subcutaneously with very little risk. 3. Many of the operations on the eye are essentially examples of this class, altlhough the punctures are made tlhrough textures differing from the skin: for example, the needle operations for cataract, drilling, etc.; also the operation for artificial pupil; and the irntroduction of minute scissors in canular sheaths through punctured openings in the cornea, etc. The subconjunctival division of the tendons of the recti muscles for strabismus may be mentioned as a recent improvement now attracting the notice of the profession. This operation was published by M. Guerin, in the year 1840. Mr. C. Brooke, Mr. Clitchett, and Mr. Holthouse, are the surgeons who have brought its merits before the profession in this country. Among the advantages, the appearance of the eyes, a diminished tendency to eversion, etc., belong to this improvement. 4. In one category may be included numerous operations for the evacuation of the fluid contents of cavities antd tumours, either not produced by inflammation, or in which inflammation does not exist at the period of operation; such as the ordinary operations for tapping in abdominal dropsy, in spina bifida, cystic tumours, hydrocele, hydroceplhalus, and collections of fluid under a great variety of circumstanices. 5. Some operationts for the removal of deformities, in which the subcutaneous method is adopted simply to avoid inflammation; such as Dieffenbach's treatment of depressed cicatrices by dividing the subjacent adhesions frequently connected with the periosteum. When these depressed cicatrices occur about the face, neck, arms, or fingers, unsightly appearances may be thus removed. To this class also belongs Dieffenbach's method of removing some of the deformities of the nose, such as depressions of the cartilaginous ridge or the aloe, by subcutaneous divisions of the cartilages in some cases, and in others by inserting a small knife into the nostlil, and subsequently restoring the form by filling the nostril during the healing. All these operations are performed subcutaneously, with the object of avoiding inflammation and its consequences. CLASS II. The operations included in the second class are performed subcutaneously, not only with the object of avoiding inflammation, but also of obtaining a new connective tissue between the (livided parts, formed independently of the inflammatory process, and adapted to the restoration or improvement of the functions of the part. This new connective tissue may be either a reproduction or new formation of the normal tissue of the part, when the structure divided is capable of reproduction; or it may be simply a fibro-cellular tissue which may serve the purpose of a new connecting bond of union to the divided structures, when they are not capable of reproduction. 1. The operation in which the above mentioned objects are best accomplished is subcutaneous tenotomy. By this operation, a new formation of perfectly formed tendon is obtained, of sufficient length for the purpose required, by organisation of a proper reparative material effused, independently of the inflammatory process. It has been satisfactorily proved by Mr. Paget that neither the effusion of blood nior the accession of inflammation are necessary to this process; but, on the contrary, that both the effusion of blood and inflammation retard this reparative process, and render it less perfect in proportion to the extent to which they exist. 2. Subcutaneous myotoiny is essentially similar to subcutaneous tenotomy, but differs from it in its results in this re. spect-that the newly formed connective tissue is unlike the structure which it serves to connect. The principal applications of this operationi are the subcutaneouis division of the sterno-mastoid muscle for wry-neck; the subcutaneous division of the spinal muscles for lateral curvature of the spine, sugg,ested and still extensively practised by MA. Guerin; and the subcutaneous division of strictures of the urethlra. The subconjunctival operation for strabismus, which has been already alluded to in the first class, cannot properly be included in tlhe series we are now considering; because, in this operationi, it is not the ol-ject to obtain elongation of the divided muscle o!r tendon by the formation of a new connective tissue, but simply to detach the insertion of the muscle from the globe, with the object of gaining a new attachment in a more appropriate place. CLASS III. The operations included in the third class are performed subcutaneously, with the object of avoiding excessive inflammation, where the occurrence of inflammation cannot with certainty be prevented.