CLINICAL LECTURES AND ESSAYS.

THE VARIOUS RISKS OF OPERATIONS.

LECTURE I.

STUDENTS are always warned against a devotion to the operating theatre. And there is some wisdom in the warning; but it is very generally neglected. The reasons for liking to see operations are so many and strong and, for the most part, so bad, that it is useless to argue against them. I will therefore try to turn to good use your taste for operations, by trying to provoke you to study a subject connected with them which is not less important than the art of operating-the subject, namely, of the influence of various conditions of patients on the consequences of operations performed on them. You hear me talk in the wards of bad and of good subjects for operation, and of greater and less risks of life; and in one case I express fears of the effects of shock; in another, of erysipelas; in another, of slow and imperfect healing: and you may fairly ask to be taught what, in all these matters, I profess to know or believe. In this and some following lectures I will try to teach you; not because I can tell you more than is known by most of those who are largely

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engaged in surgery, but because I cannot refer you to any book in which you may learn nearly so much upon the matter as you ought to know.

The average risk of life from the effects of any surgical operation may be estimated from tables such as are published in our hospital-reports. And, if an operation be frequently performed, the variations of its risk in each sex, and at different times of life, may be similarly estimated as averages. But it is not within the capacity of tables to supply the means of reckoning the variations of risk dependent on the great variety of personal conditions that we have to do with among the sick. Tables cannot yet tell the several or united influences of differences of constitution, of sound or unsound health, of diseases of internal organs, of race and temper and habits of life. Yet the question of the safety of an operation may turn on these very things. And not only of its safety, but of its utility; for there are some cases in which operations are improper, not because of the risk of life, but because the patients have such peculiarities of constitution that they would suffer more pain or loss of time or of health from an operation than even the cure of their disease would justify. In short, you will find that, if you are to do more good than harm by operative surgery, you must acquire skill in detecting, and, if possible, amending, the defects of health which make operations unsafe or unsatisfactory.

Now, first, we ought to have a good standard of health to which we might refer as the fittest for bearing operations. Such a standard is not to be found among those who, on some reckonings, might be taken for

models of health-those, namely, who have excellent health for either pleasure or an active working life. These are not the best for recovery from operations. Amputations for injuries of limbs, which are, of course, performed for the most part on persons injured while in good health, are about twelve per cent. more fatal than similar amputations for diseases. And the apparent disadvantages of full health which this fact illustrates are to be seen not only in the greater mortality of similar operations, but in the manners and rates of healing of those who recover. You may see two amputations done on the same day one, say, on a strong man whose limb has just been crushed; the other on a man utterly enfeebled by old disease of a joint. And then, you may not rarely see, that the healing of the strong man requires a much longer time, and is interrupted by many more untoward events, than that of the weak one.

Do not let me, however, seem to imply by these facts that health is, in itself, a worse condition than disease is for recovery from injuries. It is far more probable that the comparative ill doing of the healthy is due to their circumstances. They have to bear the shock of their injury as well as of the operation; their mental distress is much greater than that of those who are relieved from disease; they are subjected to a great and sudden change of habits, and have to give up many of the customs by which they sustained the health that was fit for pleasure or for work. Especially they have to give up the active mental and bodily pursuits in which they excreted largely the large refuse matter of their foods and tissue-waste. But, however this may be, they from whom we might

take standards of health for some purposes do not supply such standards for studying the consequences of operations. Where then shall we find the lowest rates of mortality and other mischiefs? Perhaps you may find them in a class whom you may often study here. We have a large number of printing-offices in the neighbourhood of the hospital; and every office employs many boys from twelve to sixteen years old; and hardly a week passes but we have one or more of these boys brought-in crushed by the printing-machines. Fingers, hands, and arms are thus mutilated; and I know no class of patients that recover more remarkably. Not only do they not die, but their wounds heal steadily and quickly; they escape erysipelas and spreading suppurations and secondary hæmorrhages; and often, when, to save any piece of a hand, we leave bits of skin that seem as if they could not live, they yet do live and grow good scars.

I know no class of persons who are better subjects for operations than these boys. As Mr. Callender1 has pointed out, our success with them helps to bring us the credit of a very low rate of mortality in amputations of the upper extremity. You may, however, find individuals, whom I. cannot classify, who do bear operations even better. For operations in boys are commonly followed by very sharp traumatic fever, which wastes and weakens them, though it rarely does more harm. But occasionally one meets with patients in whom even a severe operation is followed by neither fever nor any other trouble whatever. I can give you no exact general description of such patients, but I believe you will find them among those who, except 1 St. Bartholomew Hospital Reports,' vol. v. p. 248.

for some local disease requiring the operation, are of sound health, and whose disease, without disturbing their natural tranquillity of mind and constitution, has induced them to live as invalids, carefully and very temperately, never exhausting themselves. They are naturally cheerful healthy persons, to whom an operation brings no great change of habits, but promises release from great unhappiness.

Taking these as the best subjects for operations, and believing that the best possible recovery is one in which the wound heals without inflammation and without fever, we may speak of others as good, or not bad, or bad, or very bad-terms too ill-defined indeed, but as accurate as any knowledge of mine will justify me in using.

of

age

Among the various differences of patients, difference is probably that with which we may connect the most regular average difference in capacity to bear operations. I believe that, after two or three years old, the increase of age is attended with a proportionate increase of liability to death and other ill consequences of operations. Our hospital-reports and all similar tables will show you this; but there are many things within the general rule you should learn.

that

Young and healthy children are chiefly in danger through the shock of operations, and they bear pain very ill-it adds much to the danger of the shock. But if the shock and pain be well passed, they are in less risk than older patients. Especially, they are singularly little liable to pyæmia after wounds-a strange contrast to their liability to it in association with acute necrosis.1

1 See Note I.