SURGERY. 718 SURGERY. ly -widened, mth corresponding refinements in their treatment. Not the least important factor in the great progress which has been made in surgery and in medicine also is the method by which the sub- ject is now taught, and the candidate for the degree of doctor in medicine is now qualified to undertake the management of the cases he may be called upon to treat. Up to twenty years ago the instruction to medical students consisted very largely of didactic lectures on the various branches of medicine, supplemented by clinics at which various diseases were demonstrated and their treatment indicated or carried out by the professors. The student but rarely came into contact with the patient. With the better ap- preciation of the value of laboratory methods of instruction in the natural sciences which were originally adopted by Hunter and revived and insisted upon by Huxley, they began to be util- ized in medical schools, and were gradually elab- orated until at present in abnost every de- partment the student gains his information and experience in that way. The result is that didactic lectures have been greatly diminished in numbers. During the first year of instruction the medical student is introduced in this way to normal human anatomy and physiologj'; in the laboratories he studies the gross and minute structure of the bodj- and the functions of the tissues of which it is composed. During the second year he is taught by the same means the general process of deviation from the normal that constitutes disease. During the third year he studies specific instances of deviations from the normal and learns to identify them as par- ticular diseases. At this time he is brought into contact with patients suffering with the diseases with which he has more or less familiarized him- self in the laboratory and concerning whose causation and pathology he is fully informed, but whose symptoms and treatments he has yet to learn. The laboratory method is still pur- sued, but the dispensary and the hospital have now become for the student his laboratory, and it is in them during his fourth year that he spends the major part of his time. Thus up to the point of gaining experience in performing op- erations the student is as well instructed as he can well be. This field is well covered by the performance of operations upon the cadaver where practically all of the major and minor operations can be as well practiced as upon the living; and for special purposes operations can be carried out upon the dog. As time has progressed and the treatment of diseases peculiar to particular regions has be- come more refimed, special divisions of surgery have naturally arisen; and this specialization has contributed in no small degree to the rapid- ity of the development of surgery. There are now the well-recognized departments of ophthal- mology, treating of diseases of the eye ; otology, treating of diseases of the ear; rhinology and laryngology, treating of diseases of the nose, throat, and larynx ; gynecology, treating of dis- eases of the female; genitourinary surgery, treating of the diseases of the male; dermatol- ogy, treating of diseases of the skin ; orthop.Tdic surgery, treating of deformities growing out of diseases of the bones and joints. In the case of all of these specialties the feature that makes them departments of surgery is the fact that the diseases peculiar to each are treated by me- chanical means, either b3- the application of fixed apparatus to be continually worn throvigh long periods or by bloody or non-bloody proced- ures whose duration is brief. Operatio>s. The purpose in view in designing operations is very variable and scarcely admits of fornmlation with any accuracy. They may be planned in case of injuries to close superficial or deep-seated wounds, to stop bleeding, to facili- tate the adjustment of broken bones or the re- duction of dislocated joints, to remove foreign bodies, or to make disinfection and drainage easier. In inflammations operations may be re- quired to evacuate pus, to establish drainage, or to remove inflammatory tissue. In case of tu- mors, operations are done for their removal. In deformities, operations may be required to re- store the normal contour of the region. In the contemplation of a typical operation to be per- formed under average circumstances several fac- tors necessarily come up for consideration in detail: (1) The operating room, instruments, dressings. (2) Preparation of the patient. (3) Preparation of the surgeons. (4) The operation. (5) After-treatment. (1) The Operating Room. — This should be of good size, well lighted, and of a temperature of between 70° and 80° F. All furniture, car- pets, and hangings should be removed, the walls and ceiling rubbed over with moist bread crumbs, and the floor scrubbed. The operating table should be made especially for the purpose. On each side of the table and at its head there should be one or two small tables, those on the operator's side for the instrument trays, those on the assistant's side for the sponges, towels, dressings, etc., and that at the head for the ansesthetics, stinuilants, etc. On each side of the table there should be a large basin in which the hands of the operator and his assistant may be rinsed from time to time. The instniiiirnts vary with the character of the operation to be performed. They should be made entirely of metal to withstand the heating necessary for sterilization, and as smooth as possible to avoid lodgment for bacteria. They are sterilized im- mediately before use by boiling for fifteen min- utes in a 1 per cent, solution of sodium carbonate, and are then transferred to trays themselves sterilized by thorough washing in 0.2 per cent, solution of bichloride of mercury and lined by sterile towels. The suture and Ur/ature ma- terials are also sterilized, silk by being exposed to steam at about 250° F. for one hour, catgut by boiling in absolute alcohol under pressure for one hour. Dressings composed of absor- bent material (usually cheese-cloth and cot- ton) and the pledgets of gauze with which tfie wound is kept free from blood during the prog- ress of the operation are sterilized by being ex- posed to steam at 250° for one hour. The basins, trays, and other receptacles used during operations are sterilized by prolonged submer- sion in strong (0.2 per cent.) solutions of corro- sive sublimate. The solutions used are 0.1 per cent, bichloride of mercury for the hands and towels: for douching wounds 0.6 per cent, solutions of sodium chloride are employed, ster- ilized by being boiled in cotton-plugged flasks for one liour on two occasions. (2) Prrparatidn of the Patient. — ^Twenty-four hours before operation the skin at the site
