Surgery, Or Chirnrgcry (Gr. χείρ, the hand, and έγον, labor), that department of the art of healing which appertains to the diagnosis, prognosis, and treatment of the class of diseases which require manual or instrumental measures for their cure. The sphere of surgery is more limited and at the same time more accurately defined than that of medicine. Surgery divides tissues or parts improperly united, and unites those which have been divided when they should remain in union; separates whatever has become dangerous or in-convenient to the patient; removes foreign bodies, or parts of the body which from disease or loss of vitality have become foreign, whenever they exert a hurtful influence on the animal economy; restores to their cavity or replaces in their normal position portions of the body which have become displaced; checks the loss of blood from wounded or divided blood vessels; reduces inflammations, or removes the purulent or phlegmonous matter which may have been deposited by them; repairs and corrects deformities and distortions; and effects the replacement of lost tissues.
Its means of accomplishing these results are the hand, lint, bandages, and apparatus of various kinds, cutting, crushing, and probing instruments, catheters, bougies, sounds, forceps, specula, etc, and the various forms of cauteries, direct and indirect, liquid and solid. - The earliest surgeons of whom there is any record were the Egyptian priests. According to Herodotus, we owe to them the use of the moxa and the adaptation of artificial limbs. Among the ancient Hebrews there is but little evidence of surgical skill, and that little was confined to the priests. In Greece, surgery is as ancient as the mythic period of its historv. Chiron the centaur, born in Thessaly, and skilful in the application of soothing herbs to wounds and bruises, is the legendary father of Greek surgery. But AEs-culapius, the son of Apollo, said by some to have been the pupil of Chiron, though others call him his predecessor and superior, won the highest fame in that early time for surgical skill. He is said to have been deified on account of his wonderful success about 50 years before the Trojan war.
Temples were reared for his worship, which became the repositories of surgical knowledge, at Epidaurus, Rhodes, Cnidus, Cos, and Pergamus. Homer has immortalized his two sons, Podalirius and Macha-on, the companions of Agamemnon in the Trojan war, where they rendered essential service in healing the wounds of the Grecian heroes. The Asclepiades, or reputed descendants of AEsculapius, retained the monopoly of surgery as well as medicine in their family. They had established in this period three schools of medicine, at Rhodes, Cnidus, and Cos. Pythagoras, in the 6th century B. C, established at Crotona a new school of medicine, in which his peculiar philosophy was probably applied to the art of healing; among its early pupils was Democedes, eminent as a surgeon, who when taken captive by the Persians reduced the dislocated ankle of Darius, and removed or in some way cured the cancerous breast of his queen Atossa, after the Egyptian physicians had failed. The want of anatomical knowledge, no dissections being allowed, was a fatal bar to any considerable progress in surgery.
Hippocrates (about 400 B. C.) more than any of his predecessors advanced surgical treatment; he reduced dislocations and adjusted fractures, used the trephine, applied the forceps in accouchement, made incisions into the kidney for the removal of calculi, performed amputations, and perforated the cavity of the ribs in empyema and hydrothorax. Interdicted from human dissection, he practised the dissection of the ape tribe as nearest to man in anatomical structure, and thus obtained much knowledge. For a century after the death of Hippocrates we meet few names of note in surgery. The founding of the Alexandrian school under Ptolemy Soter about 300 B. C. was another important epoch in the advance of the art. Herophilus and Erasistratus, the two great leaders of the medical school of that university, if it may be so called, were eminent both as physicians and surgeons; with them commenced the practice of human dissections. The extirpation of the spleen, and the application of remedies direct to scir-rhosities and tumors of that viscus and of the liver, were among the bold operations of Era-sistratus. To him also belongs the invention and application of the catheter in cases of retention of urine.
The pupils of these eminent surgeons invented bandages of peculiar forms, and introduced the tournicmet and contrivances for reducing dislocations of the femur. One of them, Ammonius, employed an instrument for lithontriptic purposes, anticipating Civiale's process. - Rome in the first 700 years of its history produced no surgeon of note. Celsus, who flourished about the beginning of the Christian era, was the greatest of the surgeons of ancient Rome, and his observations on injuries of the head, on cataract, on the ligature of wounded arteries, hernia, lithotomy, fractures and dislocations, amputations, and carbuncle, show considerable knowledge. Aretams, the first to use the cantharides blister, Heliodorus, Rufus the Ephesian, all of whom flourished between A.D. 50 and 120, and after them Antyllus, added to the surgical knowledge of the time new views of the treatment of injuries of the head, the resort to arteriotomy instead of venesection in sudden emergencies of inflammatory action, bronchot-omy in some acute diseases of the throat, the radical cure of hydrocele by free incision of the parts, and a more thorough investigation of diseases of the kidneys and bladder.
Galen devoted more attention to medicine than surgery, but his observations on hernia, on luxation of the femur backward, and on the application of the trephine to the sternum in empyema, are of importance. In the early period of Christianity surgery languished; the early Christians opposed dissection as strongly as the pagans, and by attributing the power of healing wounds to martyrs and their relics discouraged all efforts at improvement in surgical science. The first eminent name among the surgeons of the dark ages is Aetius (500 to 550), whose surgical writings are numerous and valuable. He practised scarification of the extremities in anasarca, operated for aneurism, endeavored to dissolve urinary calculi by internal remedies, discussed hernia with great ability, and wrote on encysted tumors, injuries to nerves and tendons, diseases of the eyes, etc. Alexander of Tralles, a younger contemporary of Aetius, wrote treatises, now lost, on diseases of the eye and on fractures, which were highly commended for their originality by some of his successors. Paulus AEgineta, in the 7th century, was a surgeon of eminence and considerable originality. His sixth book has been considered by many as the best body of surgical knowledge prior to the revival of letters.
He recommended topical in preference to general bleeding, as more effective in reducing local inflammation; resorted to copious venesection to accelerate the painful descent of calculi through the ureters; opened internal abscesses with caustics; defined the points for performing paracentesis in ascites; made his incision in lithotomy on one side of the raphe instead of the centre as Celsus had recommended; practised both laryngotomy and tracheotomy, the latter as a means of carrying on respiration during occlusion of the larynx; treated of fractures of the patella; and was the originator of the obstetric operation of embryotomy. - The Arabian physicians, who rose into distinction as those of the West declined in reputation, did little for surgery. Rhazes (about 900) described for the first time spina ventosa and spina bifida, cauterized the wounds from the bites of rabid animals, opposed the use of the knife in cancer except when limited and when the whole tumor could be removed, and gave a clear and satisfactory description of the treatment of hernia. Avicenna (died about 1036) introduced the flexible catheter.
Albucasis (died about 1106) introduced an instrument for the cure of fistula lachrymalis, invented the pro-bang, and in wounds of the intestine practised union of the divided parts by suture with success. - In Catholic Europe medical practice and what of surgery remained was mostly in the hands of the clergy until, by the edict of the council of Tours in 1163, they were interdicted from all surgical practice. The Jews were at this period and for a century or two later in high repute as physicians, but they seem to have had a dislike to surgery. Guy de Chau-liac, a priest, compiled from the Greek and Arabian authors the earliest work of modern times on surgery, but with very little judgment of what was worth retaining. For two centuries and more surgery was mainly in the hands of the illiterate barber surgeons. The revival of surgical science dates from the appearance of Vesalius (died 1564) as a teacher of anatomy in Italy, followed soon after by Fallo-pius and Eustachius. Surgery was then for the first time put upon a sound and scientific basis, that of careful dissection, and Ambroise Pare, a French army surgeon who had educated himself in anatomical science, was the first of its great lights.
He was surgeon successively to four kings of France, and was attached to the French armies as surgeon-general down to 1569. To him we owe the revival and improvement of the practice of tying the arteries after operations or wounds, instead of cauterizing them with hot iron or boiling oil. The pupils of Pare added little lustre to their master's name; but in Italy at the close of the 16th century Fabricius ab Acquapendente flourished at Padua, and his Opera Chirurgica, the first really valuable treatise on surgery of modern times, passed through 17 editions. He was the preceptor of Harvey. Wiseman, sergeant surgeon to Charles II., was the first eminent surgical writer and practitioner in England. His recommendation of immediate amputation in military practice, when the preservation of the limb was impossible, has been followed from that time to the present. He left eight treatises on surgery, which are not without value even at the present day. The flap operation in amputation is claimed for James Young, an English surgeon contemporary with Wiseman, and also for two French surgeons, Verduin and Sabaurin, of the same period. In Germany during this century, Hildanus, Scultetus, Purmann, and Heister were the principal surgical writers and practitioners.
In Italy the principal names of note toward the close of the 16th and in the 17th century were Talia-cotius, the originator of the restorative surgery in Europe; Caesar Magatus, who greatly simplified the treatment of wounds; and M. A. Se-verinus, who banished the salves and plasters which in Italy had usurped the place of operations. The 18th century witnessed a still greater advance in the science. In England, Percival Pott, well known for his investigation of that form of caries of the vertebra known by his name (see Spinal Diseases), and the most judicious writer of modern times on fractures, amputations, injuries of the head, and diseases of the spine; John and William Hunter, the former the greatest master of the principles of surgery in the profession; Cheselden and Douglas, both famous as lithotomists; and the two Monros, father and son, are among the great names of the surgical profession. In France flourished La Peyronie, at whose instance Louis XV. in 1731 founded the academy of surgery; Jean Louis Petit, the greatest French surgeon of the 18th century; Ledran, Garangeot, and the illustrious Desault, the originator of clinical surgical instruction and the inventor of numerous admirable apparatuses for the treatment of fracture.
Among the celebrated surgeons of other European countries were Molinelli, Morgagni, Scarpa, Bertrandi, and Moscati in Italy; Deventer, Albinus, and Camper in Holland; and Plainer, Roderer, Rambilla, Theden, and Richter in Germany. During the 18th century the ligature of aneu-rismal arteries of large size, the treatment of hernia and fistula in ano, the cure of fistula lachrymalis, and the skilful management of dangerous and difficult parturitions, were the most important branches of surgery in which there was a material advance from the preceding century; the proper construction of instruments also received great attention. The 19th century has, however, done more for the improvement of this science than all the centuries which have preceded it. In England, Abernethy, Sir Astley Cooper, Liston, and others of the highest reputation have passed away, and others hardly less eminent remain; in France, Dupuytren, Roux, Lisfranc, and Larrey have had no superiors either before or after them. The following may with propriety be particularized as among the improvements of the age in surgery: the introduction of anaesthesia; resection of the bones at the joints; the preservation of the periosteum and consequent development of new bone; partial amputations of the foot, as instanced in the operation of Lisfranc for the removal of the metatarsus, and of Chopart, Symes, Malgaigne, and Pirigofif for disarticulation of tarsal bones; the amputations at the thigh and shoulder joints; the ligature of arteries within the trunk and immediately at their departure from it; the resection and removal of portions or even the whole of the upper or lower jaw; the operations for cleft or deficient velum palati or palatine vault; the opening by longitudinal section of the air passages at different points to avoid asphyxia; the resection and extirpation of the uterus, of the ovaries, and of the lower portion of the rectum; the introduction of the silver suture, especially in operations on the viscera, as for recto-vaginal and vesico-vaginal fistulaa; the adoption of the immovable apparatus for fractures; the processes for remedying disunited fracture; the substitution of milder means for the trephine in all except the most serious cases; the improved treatment of ulcers and abscesses; the cure of the most formidable aneurisms by the ligature of the carotid, subclavian, axillary, humeral, and external and internal iliacs; the treatment of varicose veins; the successful treatment of calculus by lithotrity, in consequence of the great improvements made in the processes and instruments; the diagnosis and treatment of tumors, whether encysted, fatty, vascular, or malignant; the cure of strabismus, and the generally improved treatment in diseases of the eye, including the invention of 'the ophthalmoscope by Helmholtz in 1851, and the reformation of ophthalmic medicine and surgery carried on by Von Graefe, Donders, Bowman, Toynbee, Wilde, Von Troltsch, Politzer, and others; the restorative processes, by which the nose, lip, and other parts are reformed from adjacent tissues; the treatment of harelip and of club-foot; and the notable advance consequent upon the conservative treatment of gunshot and other wounds of the brain. - As from the nature of their duties suits for malpractice are more often brought against surgeons than against physicians, it will be appropriate here to speak of their legal obligations, though the same laws apply to practitioners in any of the branches of medicine.
In undertaking the treatment of a patient, the surgeon enters into a legal obligation and assumes legal liabilities, which, though seldom expresslydefined, are yet, in the apprehension of the law, fixed and certain. The law holds that he contracts for the possession of that reasonable degree of learning, skill, and experience which the members of his profession ordinarily possess. Those also who, like oculists, aurists, or dentists, claim to be particularly conversant with and skilful in the treatment of the diseases of single organs, must be held to a peculiar responsibility. The same is true of surgeons of great pretensions in large cities as compared with those residing in remote and thinly settled districts. In undertaking a case, the surgeon also contracts that he will apply the skill which he possesses, whatever be its degree, with reasonable and ordinary diligence and care. Extraordinary care is no more implied than extraordinary skill; nor is the practitioner supposed to guarantee' a cure, though he may if he chooses contract to effect a cure, and then he must answer for a failure.
The practitioner's skill in any case will ordinarily be required to embrace those phases and phenomena which usually characterize the dominant disease; and any mischance which connects itself immediately with these will involve the question of skill. His diligence and care will be exercised in watching for and guarding against the accidental influences which, if overlooked, may delay or even prevent the restoration of the patient. If he have brought ordinary skill and care to the treatment of his case, the surgeon is not responsible for want of success nor for mistakes in cases of real doubt and uncertainty. The surgeon's liability in cases of malpractice is ordinarily only a civil one, and the injury he does can usually be compensated by damages. But, in cases where death has followed the treatment, and it has seemed to be the direct consequence of the treatment, there have been, not unfrequently, charges of criminal malpractice preferred against the medical practitioner. To constitute a crime, there must be a malicious or criminal intent. This intent may exist in an actual design, or the law will infer it from gross rashness or want of circumspection. - Where no statutory prohibition intervenes, all regular and irregular practitioners are to bo placed on the same footing.
Leaving out of consideration cases of express malice, which would hardly be included under the designation of malpractice, our topic is reduced to those cases in which the charge is founded upon gross ignorance, gross negligence, or gross rashness. With particular reference to the charge of manslaughter, the law, especially in England, is that "if one, whether a medical man or not, profess to deal with the life or health of another, he is bound to use competent skill and sufficient attention; and if he cause the death of the other through a gross want of either of these, he will be guilty of manslaughter;" or as an eminent American authority, Mr. Bishop, states the law: " The carelessness in a medical man which, if death follow, will render him liable for manslaughter, is gross carelessness, or, as it is more strongly expressed, the grossest ignorance or most criminal inattention".