_Amputations and Compound Fractures._—Having now traced the different
modes of thought which have aided surgical progress in the nineteenth
century and the improved means of investigation, let us turn finally to
the progress in individual operations. As to amputations and compound
fractures, I have already indicated the immense improvements which have
followed the introduction of anæsthesia, and especially of antisepsis,
which have brought the mortality of amputations down from fifty or
sixty per cent. to ten or fifteen per cent., and in compound fractures,
once so dreaded, since the mortality was not infrequently as high as
two out of three, to a relatively insignificant danger.
_Tumors._—In no department, perhaps, has the introduction of
antisepsis, and the use of catgut and silk ligatures after the
antiseptic method, brought about a greater improvement than in
operations for tumors. The startling reluctance of Sir Astley Cooper
to operate on King George IV. for so simple and small a tumor as a
wen, lest erysipelas might follow and even destroy his life, is in
marked contrast with the success and therefore the boldness of modern
surgeons. Tumors in all parts of the body, whether they be external or
internal, whether they involve the wall of the chest or are inside the
abdomen, are now removed with almost perfect safety. Anæsthesia has
made it possible to dissect out tumors in so dangerous a region as the
neck, where the surgeon is confronted with adhesions to the jugular
vein, the carotid artery, and the nerves of the neck and of the arm,
with the greatest impunity. Such an operation not uncommonly lasts from
three-quarters of an hour to an hour and a half, and involves often
the removal of two or three inches of the jugular vein and many of the
large nerves, the removal of which a few years ago would have been
deemed an impossibility.
_Goitre._—One of the most striking instances of progress is operations
on goitre. Writing in 1876, the late Professor Samuel D. Gross noted it
as something remarkable that Dr. Green, of Portland, Maine, had removed
seven goitres with two deaths, and the late Dr. Maury, of Philadelphia,
had extirpated two goitres with one death. In marked contrast to this
Professor Kocher, of Berne, in 1895, reported one thousand cases, of
which eight hundred and seventy were non-cancerous, and he lost of
these last but eleven cases, or a little over one per cent. In 1898 he
reported six hundred additional cases, with only one death in the five
hundred and fifty-six non-cancerous cases, or a mortality of only 0.1
per cent. It will be seen, therefore, that an operation which a few
years ago was excessively fatal has become almost, one might say, a
perfectly safe operation.
_Surgery of the Bones._—Operations on bones, apart from amputations,
show also a similar improvement. In cases of deformity following
fracture we now do not hesitate to cut down upon the bone and
refracture it or remove the deformed portion, join the ends together,
dress the part in plaster of Paris to secure fixation, and have the
patient recover with little or no fever and no suppuration. Above the
elbow a large nerve runs in a furrow in the arm bone, and in case of
fracture this is liable to be torn and a portion of it destroyed. The
result of it is paralysis of all the muscles on the back of the forearm
from the elbow down and consequent inability to extend either wrist or
fingers, making the hand almost useless. In a number of cases the nerve
has been sought for and found, but the ends have been too far apart
for successful union and sewing them together. In such cases we do not
hesitate now, in order to bring the two ends of the nerve together,
to remove one or two inches of the arm bone, wire the shortened
bone, sew the now approximated ends of the nerve together, put the
arm in plaster, and as soon as the wound is healed, with appropriate
later treatment to the muscles we can obtain in a reasonable number
of cases a perfect, or almost perfect, union of the nerves with a
re-establishment of the usefulness of the hand.
In very many cases the bones are deformed as a result of rickets, and
in some cases in consequence of hip-joint disease. In such cases the
leg is crooked or flexed, and cannot be used for walking. Such cases
of stiff joints and crooked legs are now operated on, one might say,
wholesale. At the International Medical Congress, held in Copenhagen in
1884, Professor Macewen, of Glasgow, reported 1800 operations on 1267
limbs in 704 patients, in which he had sawn or chiselled through the
bones so as to fracture them, placed them in a straight position, and
after a few weeks the bone has become consolidated and the leg or arm
made straight. Every one of these operations was successful, excepting
five cases, and even these deaths were not due to the operation, but
to some other disorder, such as an unexpected attack of pneumonia,
diphtheria, or scarlet fever.
_Surgery of the Head and Brain._—In the surgery of the head we find
one of the most remarkable illustrations of the modern progress of
surgery. Fractures of the skull have been the most dangerous and fatal
of accidents until within a short time. Of course, many of them must
necessarily, even now, be fatal, from the widespread injury to the
bones and the brain. But our modern methods, by which we can disinfect
the cavities of the ear, the nose, and the mouth, with which these
fractures often communicate, and through these avenues become infected,
are so successful that such cases, instead of being looked upon as
hopeless, are in a majority of instances followed by recovery. Even
gun-shot wounds, in which the ball may remain inside the cavity of the
head, are successfully dealt with, unless the injury produced by the
ball has been necessarily fatal from the start. Fluhrer, of New York,
has reported a very remarkable case of gun-shot wound, in which the
ball entered at the forehead, traversed the entire brain, was deflected
at the back of the skull, and then pursued its course farther downward
in the brain. By trephining the skull at the back he found the ball,
passed a rubber drainage tube through the entire brain from front to
back, and had the satisfaction of seeing the patient recover.
Until 1884 it was excessively difficult to locate with any degree
of accuracy a tumor within the brain, but in that year Dr. Bennett,
of London, for the first time accurately located a tumor within the
skull without there being the slightest evidence on the exterior of
its existence, much less of its location. Mr. Godlee (surgeons in
England are not called “Dr.,” but “Mr.”) trephined the skull at the
point indicated, found the tumor, and removed it. True, this patient
died, but the possibility of accurately locating a tumor of the
brain, reaching it and removing it, was now demonstrated, which is
far more important to humanity at large than whether this individual
patient survived or not. Since then there have been a very large
number of tumors successfully removed. The latest statistics are those
of Von Bergmann, of Berlin, in 1898. He collected 273 operations for
brain tumors, of which 169 (61.9 per cent.) recovered, and 104 (38.1
per cent.) died. This is by far the best percentage of results so
far reported, but there is reason to believe that with the constant
improvement in our ability to locate such tumors and in our methods of
removing them, the mortality rate will be still further lessened.
Even more successful than the surgery of brain tumors has been the
surgery of abscess of the brain. I have no available statistics of
the exact numbers, but it is certain that several hundred have been
operated on, and with even better success than in the case of brain
tumors. The most frequent cause for such abscesses is old and neglected
disease of the ear. No child suffering from a “running from the ear,”
which is especially apt to follow scarlet fever and other similar
disorders, should be allowed to pass from under the most skilled
treatment until a cure is effected. This is the commonest cause of
abscess of the brain. The inflammation in the ear, which begins in the
soft lining of the cavities of the ear, finally extends to the bone,
and after years of intermittent discharge, will suddenly develop an
abscess of the brain, which, if not relieved, will certainly be fatal.
Prompt surgical interference alone can save life, and, happily, though
we cannot promise recovery in all, a very large percentage of success
is assured.
In epilepsy, as a result of injuries of the head, in a moderate number
of cases, we can obtain a cure of the disease by operation, but in the
great majority of cases, and, one may say, practically in all of the
cases in which the epilepsy originates “of itself,” that is to say,
without any known cause, it is useless to operate, certainly at least
after the epileptic habit has been formed. Possibly were operation done
at the very beginning we might obtain better results than experience
thus far has shown us is possible.
Very many cases of idiocy are constantly brought to surgeons in
the hope that something can be done for these lamentable children.
Unfortunately, at present surgery holds out but little hope in such
cases. In a few exceptional instances it may be best to operate, but a
prudent surgeon will decline to do any operation in the vast majority
of cases.
_Surgery of the Chest and Heart._—The chest is the region of the
body which has shown the least progress of all, and yet even here
the progress is very marked. When, as a result of pleurisy, fluid
accumulates on one side of the chest, even displacing the heart, we
now do not hesitate to remove an inch or two of one or more ribs and
thoroughly drain the cavity, with not only a reasonable, but in a
majority of cases, one may almost say, a certain, prospect of cure.
We have also entered upon the road which will lead us in time to a
secure surgery of the lung itself. A few cases of abscess, of serious
gun-shot wound, attended by otherwise fatal hemorrhage, and even of
tubercular cavities in the lungs have been successfully dealt with, but
the twentieth century will see, I have no doubt, brilliant results in
thoracic surgery.
One of the most striking injuries of the chest has recently assumed a
new importance, viz., wounds of the heart itself. In several instances
an opening has been made in the bony and muscular walls of the chest,
and a wound of the heart itself has been sewed up. The number is as
yet small, but there have been several recoveries, which lead us to
believe that here, too, the limits of surgery have by no means been
reached.
_Surgery of the Abdomen._—Of the abdomen and the pelvis a very
different story can be told. These cavities might almost be called the
playground of the surgeon, and the remarkable results which have been
obtained warrant us in believing that even greater results are in store
for us in the future.
In the earlier part of this article I spoke of the advantages of
the study of the pathological anatomy or the diseased condition of
individual organs. Perhaps no better illustration of the value of
this can be given than in the studies of appendicitis. This operation
has been one of the contributions to the surgery of the world in
which America has been foremost. While there were one or two earlier
papers, Willard Parker, of New York, in 1867, first made the profession
listen to him when he urged that abscesses appearing above the right
groin should be operated on and the patient’s life saved. But it was
not until Fitz, of Boston, in 1888, published his paper, in which
he pointed out, as a result of a study of a series of post-mortem
examinations of persons dying from such an abscess above the right
groin, that the appendix was the seat of the trouble, that this so
frequent disease was rightly understood and rightly treated.
As a result of the facts gathered in his paper, the treatment was
perfectly clear, not only that we ought to operate in cases of abscess,
but that in the case of patients suffering from two or more attacks,
and often from even one attack of appendicitis, the appendix should be
removed to prevent such abscess.
The mortality in cases in which such an abscess has formed is, perhaps,
quite twenty or twenty-five per cent., whereas, if patients are
operated on “in the interval,” that is to say, between attacks, when
the abdominal cavity is free from pus, the mortality is scarcely more
than two or three per cent., and may be even less than that.
Surgeons are often asked whether appendicitis is not a fad, and whether
our grandfathers ever had appendicitis, etc. As a matter of fact, in
my early professional days, appendicitis was well known. It was called
“localized peritonitis” or localized “abscess,” but while the disease
was very frequent, its relation to the appendix was not recognized
until from his study of its pathology an American pointed it out. Even
now European surgeons, with a few exceptions, are not alive to the need
for operation in such cases.
There is little doubt that the great prevalence of grippe during the
last few years has increased the number of cases of appendicitis,
both of them being catarrhal conditions of the lining membrane of the
same continuous tract of the lungs, the mouth, the stomach, and the
intestines.
One of the most fatal accidents that can befall a patient is to have
an ulcer of the stomach perforate so that the contents of the stomach
escape into the general abdominal cavity. Until 1885 no one ventured
to operate in such a case. In an inaugural dissertation by Tinker, of
Philadelphia, two hundred and thirty-two cases of such perforating
ulcers of the stomach were reported, of which one hundred and
twenty-three recovered, a mortality of 48.81 per cent. In not a few of
them, if prompt instead of late surgical help had been invoked, a very
different result would have been reported. If no operation had been
done, the mortality would have been one hundred per cent.
In cancer of the stomach itself we are able, as a rule, to make a
positive diagnosis only when a perceptible tumor is found. By that
time so many adhesions have formed, and the infection has involved the
neighboring glands to such an extent, that it is impossible to remove
the tumor, but the statistics even here are not without encouragement,
at least for comfort if not for life. In many cases the tumor has
been removed and the stomach and intestine joined together by various
devices, and the mortality, which is necessarily great, has been
reduced by Czerny to twelve per cent. and by Carle to seven per cent.
Even the entire stomach has been removed in several cases, and recovery
has followed in about one-half. Most of these patients, however, have
died from a return of the disease.
When, as a result of swallowing caustic lye or other similar
substances, the gullet (the œsophagus) becomes contracted to such an
extent that no food can be swallowed, we now establish an opening into
the stomach through which a tube is inserted at meal-time, and the
patient has his breakfast, dinner, and supper poured into his stomach
through the tube. If the stricture of the œsophagus is from malignant
disease, of course this only prolongs life by preventing a horrible
death by starvation, but in cases in which it is non-malignant life
is indefinitely prolonged. The mortality of such an operation is very
small.
By a freak of nature or by disease the stomach sometimes is narrowed
in the middle, forming what is called an “hour-glass stomach.” In such
a case we open the abdomen, make an opening into the two parts of the
stomach and unite the two so that we re-establish the single cavity
of the stomach. The mortality of the operation is very slight, eight
per cent. Again, sometimes the stomach becomes unduly dilated, thus
interfering seriously with its function. A number of surgeons in such
cases have simply folded over the wall of the stomach upon itself and
have sewed the two layers together, taking a plait or “tuck” in the
stomach wall, and have restored it to its normal capacity and function.
One of the most important advances has been made in the treatment
of gall stones. The bile in the gall bladder is in a state of
quiescence, which is favorable to a deposit of crystals from the bile.
These crystals become agglutinated together into larger or smaller
solid masses called gall stones. Sometimes the number of these is
very small, from one to four or five; sometimes they accumulate in
enormous numbers, several hundreds having been reported in a number of
instances. When they are small they can escape through the duct of the
gall bladder into the bowel and create no disturbance, but when they
are large, so that they cannot make their escape, they not uncommonly
are causes not only of serious discomfort and prolonged ill-health, but
often prove fatal. Nowadays one of the safest operations of surgery
is to open the abdomen and the gall bladder and remove this menace
to life, and the great majority of such patients recover without any
untoward symptoms. Even large abscesses of the liver, and, what is
still more extraordinary, large tumors of the liver, are now removed
successfully. A year ago all of the reported cases of tumor of the
liver were collected which had been operated from 1888 to 1898,
seventy-six in all. The termination in two cases was unknown, but
of the other seventy-four, sixty-three recovered and eleven died, a
mortality of only 14.9 per cent.
The surgery of the intestines by itself is a subject which could well
occupy the entire space allowed to this article. I can only, in a very
superficial way, outline what has been done. Hernia or rupture is a
condition in which through an opening in the abdominal wall a loop of
the bowel escapes. If it can be replaced and kept within the abdomen
by a suitable truss this was the best we could do till within the
last ten or fifteen years. The safety and the painlessness of modern
surgery which have resulted from the introduction of anæsthesia and
antisepsis are such that now no person suffering from such a hernia,
unless for some special personal reason, should be allowed to rely upon
a truss, which is always a more or less treacherous means of retaining
the hernia. We operate on all such cases now with impunity. Coley has
recently reported a series of six hundred and thirty-nine cases, all of
which recovered with the exception of one patient. Even in children,
if a truss worn for a reasonable time, a year or so, does not cure the
rupture, operation affords an admirable prospect of cure.
Every now and then a band forms inside the abdomen, stretching like
a string across the cavity. If a loop of bowel slips under such a
band, it can be easily understood that total arrest of the intestinal
contents ensues, a condition incompatible with life. There are other
causes for such “intestinal obstruction,” which are too technical to
be described in detail, but this may be taken as a type of all. It is
impossible, of course, to tell before opening the abdomen precisely
the cause of the obstruction, but the fact is quickly determined in
most cases. If we open the abdomen promptly, we can cut such a band or
remove the other causes of obstruction in the majority of cases, and
if the operation has not been too long delayed, the prospect of entire
recovery is good. The mortality which has followed such operations has
been considerable, and by that I mean, say, over twenty per cent.,
but a very large number of the fatal cases have been lost because the
operation has been delayed. In fact, it may be stated very positively
that the mere opening of the abdomen to find out precisely the nature
of any disease or injury is attended with but little danger. If further
surgical interference is required, the danger will be increased
proportionately to the extent and gravity of such interference.
But “exploratory operations,” as we call them, are now undertaken
constantly with almost uniform success.
Even in cancer of the bowel, we can prolong life, if we cannot save
it. Cancer of the bowel sooner or later produces “obstruction” and
so destroys life, but in such cases we can either make a permanent
opening in the bowel above the cancer, and so relieve the constant pain
and distress which is caused by the obstruction, or, in a great many
cases, we make an opening in the bowel above the cancer, and another
below it, and, by uniting the two openings, if I may so express it,
“side-track” the contents of the bowel. If the cancer has no adhesions
and the patient’s condition allows of it, we can cut out the entire
portion of the bowel containing the cancer, unite the two ends, and
thus re-establish the continuity of the intestinal canal. As much as
eight feet, nearly one-third of the entire length of the bowel, have
been removed by Shepherd, of Montreal, and yet the patient recovered
and lived a healthy life.
Similarly in gun-shot wounds, stab wounds, etc., involving the
intestine, the modern surgeon does not simply stand by with folded
hands and give opium and morphine to make the patient’s last few hours
or days relatively comfortable, but he opens the abdomen, finds the
various perforations, closes them, and recovery has followed even in
cases in which as many as seventeen wounds of the intestine have been
produced by a gun-shot wound.
The kidney, until thirty years ago, was deemed almost beyond our
reach, but now entire volumes have been written on the surgery of the
kidney, and it is, one might say, a frequent occurrence to see the
kidney exposed, sewed fast if it is loose, opened to remove a stone in
its interior, drained if there be an abscess, or, if it be hopelessly
diseased, it is removed in its entirety. The other kidney, if not
diseased, becomes equal to the work of both.
Of the pelvic organs, it would not be becoming to speak in detail,
but one operation I can scarcely omit: namely, ovariotomy. One of my
old teachers was Washington L. Atlee, who, with his brother, was among
the first ovariotomists in this country who placed the operation on
a firm foundation. I heard a very distinguished physician in 1862,
in a lecture to his medical class, denounce such men as “murderers”;
but to-day how differently does the entire profession look upon the
operation! Instead of condemning the surgeon because he did remove such
a tumor, the profession would condemn him because he did not remove it.
The operation had its rise in America. Ephraim McDowell, of Kentucky,
in 1809, first did the operation which now reflects so much credit upon
modern surgery. The mortality of the Atlees was about one in three.
Now, owing to the immense improvement introduced by the antiseptic
methods, the deaths, in competent hands, are not over five per cent.,
or even three per cent.
The limits of this article compel me to stop with the story very
imperfectly told, but yet, perhaps, it has been sufficient in detail
to show somewhat of the astonishing progress of surgery within the
century, but especially within the last quarter of the century.
About two decades ago one of the foremost surgeons of London, Mr.
Erichsen, said, in a public address, that “surgery had reached its
limits.” How short was his vision is shown by the fact that surgery
at that time was just at the beginning of its most brilliant modern
chapter.
We have reached, in many respects, apparently, the limits of our
success, but just as anæsthesia and antisepsis and the Röntgen rays
have opened new fields wholly unsuspected until they were proclaimed,
so I have no doubt that the twentieth century will see means and
methods devised which will put to shame the surgery of to-day as much
as the surgery of to-day puts to shame that of thirty years ago,
and still more of a century ago. The methods by which this will be
attained will be by the more thorough and systematic study of disease
and injury, so as to better our means of diagnosis, and so prepare
us for immediate surgical interference, instead of delaying it, as
we now do in many cases, for want of certain knowledge; by the use
of new chemical and pharmaceutical means to perfect our antisepsis
and possibly to introduce other methods of treatment; but, above
all, we shall obtain progress by the exact experimental methods of
the laboratory. We can never make progress except by trying new
methods. New methods must be tried either on man or on animals, and
as the former is not allowable, the only way remaining to us is to
test all new methods, drugs, and applications first upon animals.
He who restricts, and, still more, he who would abolish our present
experiments upon animals, is, in my opinion, the worst foe to the human
race, and to animals, as well, for they, as well as human beings,
obtain the benefit derived from the method. He may prate of his
humanity, but he is the most cruel man alive.