surgeon, Ambroise Paré, probably the greatest of his day, in completing
his work on “Chirurgery,” made the following statement, which to us of
to-day is both amusing and pathetic. He says: “For God is my witness,
and all good men know, that I have labored fifty years with all care
and pains in the illustration and amplification of Chirurgery; and that
I have so certainly touched the work whereat I aimed that antiquity
may seem to have nothing wherein it may exceed as beside the glory of
invention, nor posterity anything left but a certain small hope to add
some things.” This great man had scarcely passed away when the practice
of surgery of his day was a thing of the past, due to the realization
of that “certain small hope” which he allowed as possible to posterity.
Every reader, when he reflects upon the crude surgery practiced in
those days, when the operations were those of necessity and not
election,—that is, were done for injuries and not for disease, done to
relieve and not to cure; when he remembers that not only antiseptics
but also anæsthetics were unknown, must be filled with sympathy for
this old gentleman, and wonder what he would think _now_ were he to see
what progress posterity has made and is still making.
It is not our purpose, however, to carry our researches so far back as
Paré’s time, but to begin with our own century and bring before the
reader the advances in surgery since the day of our grandfathers.
In the beginning of this century surgery was practiced by many great
men, men who did not enjoy the self-satisfaction of their predecessor,
Paré, but who accomplished much by constant endeavor and faithful
application to advance this art and science. They, too, realized
manifold “hopes,” and their children and grandchildren have moved
on, and to-day are still pressing forward in the line of invention
and discovery. But to us, the art of an hundred years ago appears
widely different from that of our day. Anæsthesia had not then been
discovered, no germ theory had been evolved, and, consequently, no
such thing as antiseptic or aseptic surgery was known. The abdomen
was opened for disease only, and rarely; and brain surgery consisted
solely in trepanning for fractures of the skull. Surgery was not
regarded as a specialty, but every surgeon was also an obstetrician
and a practitioner of general medicine. Outside of the treatment of
broken bones, dislocations, gunshot wounds and injuries, the surgeon
at that time operated for strangulated hernia, for stone in the
bladder—“cutting for stone,” as it was called; for cataract and for
cancer. Dentistry was just beginning to be taken up as a specialty,
and all medical men extracted teeth, and many filled their cavities.
Ophthalmic surgery consisted largely in operations for cataract, and
was done by the general surgeon. One department of the surgeon’s
education at this time was well attended to, and that was his anatomic
knowledge. Our bodies were the same then as now; and although the
surgeon dared not trespass in anatomical fields which are familiar
ground to the student of to-day, he did study the body after death, and
was quite as well informed regarding the gross anatomy of the human
body as the surgeon of to-day; and, had anæsthesia been known to him,
he would probably have accomplished nearly all that was done during the
middle of the century by his successors.
During the first quarter of the century no great advance was made in
surgery, that is, nothing revolutionizing; but many minds and hands
were at work perfecting old methods of operation and devising new
ones. They had to trust to whiskey and opium to control the pain of
the patient, and consequently operations requiring much time in their
performance were avoided when possible, and, when necessary, had to be
performed with such rapidity that the essential object aimed at was
often missed. The patient was given a large dose of laudanum and a huge
drink of whiskey or brandy, and was then held or tied on the table
while the surgeon proceeded with his work. One can readily understand
the torturing pain the poor patient had to endure, and the hurried and
often unsatisfactory operation which the surgeon had to perform. The
endurance of pain was not the worst part of the patient’s lot, for
afterward he ran the greatest risk of blood-poisoning and gangrene,
which were common complications in those days. It was the rarest thing
for even the simplest operation wounds to heal by “primary union,” as
it was called,—that is, without the formation of pus. Every wounded
surface was expected to go through a certain amount of suppuration.
Many patients lost their lives from compound fractures of their bones;
and a compound fracture, that is, where there was a wound connecting
the seat of fracture with the skin, usually meant many months in bed,
and very often the loss of the limb.
Excepting for the purposes of removing a fœtus from the womb (the
so-called Cæsarian operation, because Cæsar was from “his mother’s
womb untimely ripped”), the abdominal cavity was practically never
opened, and when it was the patient nearly always died. The operation
for the radical cure of hernia was seldom resorted to, excepting when
strangulation of the intestine necessitated operative interference
to save the patient’s life. During the latter part of the eighteenth
century the quacks, calling themselves “rupture cutters,” were not
scarce; but the great mortality of their practice produced a wholesome
fear among the people. The operation was so often fatal that most
of the best surgeons would only perform it under unusually urgent
circumstances. What caused the deaths was peritonitis, or gangrene of
the intestine, and not the method of operating; for at this time nearly
every method of operating had been devised that was in vogue fifty
years later.
Bone surgery, the treatment of fractures, dislocations, and diseases of
the bones, was greatly improved in the first half of the century, this
subject receiving more attention at the hands of surgical writers than
any other.
[Illustration: SURGICAL OPERATING ROOM, HOWARD HOSPITAL, PHILADELPHIA,
PA.]
ANÆSTHESIA.—Anæsthesia may, certainly from the patient’s point of
view, be looked upon as the greatest advancement ever made in surgery.
It was great not only for the reason that it gave the patient absolute
unconsciousness during the time of the operation, but because it
enabled the surgeon to work with greater exactness and less hurry.
The conception of the anæsthetic state did not, however, come into
being for the first time in our century, for, like most great ideas,
it agitated the minds of medical and scientific men for centuries.
Gross tells us that Theodoric, in the thirteenth century, recommended
the inhalation of a certain combination of opium, hemlock, and
other vegetable derivatives for the purpose of producing sleep, and
that in India similar combinations were for centuries in use. It is
needless, however, to say that the effect produced was nothing like
that following the use of nitrous oxide, “laughing gas,” ether, or
chloroform, and that their use never became general. Toward the close
of the last century Sir Humphry Davy and others performed repeated
experiments with nitrous oxide gas, but finally gave up in despair.
In the early part of our own century several methods of producing
insensibility to pain were recommended, such as pressure on nerves and
bleeding to the degree of producing unconsciousness, but none of them
was ever sufficiently successful to render their adoption general; and
it remained for a New England dentist, Dr. Horace Wells, in 1844, to
first use satisfactorily upon himself and his patients the complete
state of unconsciousness produced by nitrous oxide gas. This poor man,
however, failed signally when he endeavored to demonstrate its powers
before a body of medical men, and was subjected to the most unwarranted
ridicule. However, a pupil of this man, another dentist, named Morton,
two years later, experimented with ether, and finally proved upon
himself and on patients the wonderful power of the vapor. He exhibited
his discovery at the Massachusetts General Hospital at Boston, where
Dr. Warren performed an operation upon a patient etherized by Dr.
Morton. The fame of this man and his great discovery spread rapidly
over the continent and into the Eastern Hemisphere, and in 1847 Sir
James Y. Simpson in Edinburgh discovered the anæsthetic powers of
chloroform. These two agents, ether and chloroform, have existed as
rivals for professional favor for nearly half a century, one being
more popular and more generally used in one country and the other in
another. There is, however, a field for the use of both, the operator
choosing the anæsthetic to suit the individual case. In our own country
ether is more generally used in the North and East and chloroform in
the South and West. Chloroform has had more deaths attributed to its
use, but in many cases is a much safer anæsthetic than ether. It is
most amusing to observe the attitude of the so-called conservative
surgeon toward the use of anæsthetics soon after their discovery;
this is particularly true of their employment in obstetric practice,
many eminent obstetricians maintaining that the parturient woman
was intended to suffer, and referring triumphantly to the Bible for
authority. It is, however, needless to say that although many men were
at first uneasy in the use of these new-found agents, those who did
not take advantage of their wonderful powers found themselves rapidly
becoming out of date and deserted by their patients, who preferred
unconsciousness to the older method of using opium and whiskey.
Notwithstanding the great step made by the introduction of ether
and chloroform, the medical man is to-day still dissatisfied and is
continually endeavoring to discover some agent or combination of agents
which will produce insensibility to pain without unconsciousness
and without the slight danger and the uncomfortable after effects
of chloroform and ether. An ideal anæsthetic then must be a local
anæsthetic, one that will render the field of operation insensible and
be without the slightest danger to the patient.
LOCAL ANÆSTHESIA.—At the beginning of our century freezing with ice
alone, or with ice and salt, was the only method employed for producing
local insensibility. Freezing as a local anæsthetic was, however, not
extensively used until fifty years later, when Dr. Richardson of London
showed the anæsthetic effect of spraying the surface of the tissues
with ether. During the late sixties this method of freezing became
quite popular for producing local anæsthesia for small operations such
as extraction of teeth, removing nails, opening abscesses, etc., and
occasionally was employed for more protracted operations, Cæsarian
section having been performed a number of times by the aid of this
agent. The rhigolene spray was found later to be more satisfactory than
ether in many respects, and the two together were frequently used.
Another freezing agent which is now used very extensively and has
entirely supplanted those just mentioned is the chloride of ethyl.
This, when applied to the dry skin, produces in a few seconds complete
freezing, and renders the surface comparatively painless for many of
the minor surgical operations.
The properties of cocaine as a local anæsthetic were known thirty years
ago, but it was not until 1884 that Dr. Kohler of Germany demonstrated
its practical applicability. To-day most of the operations on the eye,
nose, and throat are performed under the pain prevention afforded by
this drug, and in general surgery it has an extensive field, being
found satisfactory where freezing is inapplicable or general anæsthesia
not desired, as, for instance, in removing small tumors, splinters,
ingrowing nails, etc. In the eye, nose, and throat it is applied simply
in solution to the mucous membrane, but where anæsthesia of the skin is
desired, it is necessary to inject it under the skin with a hypodermic
syringe. When used in strong solutions this remedy is dangerous, and
it has lately been shown that weaker solutions when used in larger
quantities are just as satisfactory and less dangerous.
A recent substitute for cocaine is eucaine; but, although less
dangerous, it is less satisfactory and not harmless to the tissues
themselves.
ANTISEPTIC AND ASEPTIC SURGERY.—Excepting the introduction of
anæsthesia, no greater step has ever been made in surgery than that
which was brought into use by the antiseptic and aseptic method of
treating wounds. It is now about thirty years since Sir Joseph Lister,
believing in the so-called “germ theory,” evolved by Pasteur, Virchow,
and others, advocated the use of agents which were destructive to germ
life in the treatment of wounds. At first the great antiseptic, and the
one used most generally by Lister, was carbolic acid, which was applied
to the wound in solution, and used as a spray during the performance
of operations, to protect the wound from infection by germs in the
atmosphere. It was not long, however, before it was discovered that the
danger lay not in the atmosphere but in the skin of the patient and
in the hands of the surgeon and in the condition of his instruments
and dressings; and to these sources attention was given with results
known to us all. Other antiseptics, such as bichloride of mercury and
boric acid, afterward came into use, and within the past ten years the
first of these two has largely supplanted carbolic acid, and is the one
reliable and practical destroyer of germs. The antiseptic treatment
of wounds was probably not in full swing until about 1885–1890, and
was quickly followed by the more recent aseptic method. These two can,
however, never be successfully separate, as the latter is dependent
entirely upon the former; that is, in order to render the field of
operation and the hands of the surgeon aseptic, the antiseptics must
be used. Asepsis means without poisonous germs, and, as applied to
surgical treatment, it is essential that, after the instruments, the
dressings, the patient’s skin, the surgeon’s and his assistants’ hands
have been thoroughly cleaned with soap and water and rendered free
from germs, there be use of antiseptic solutions in the wound or on
the dressings. This has been a great step forward, this discovery that
it was in the skin that the germs lurked, and that soap and water
and a scrubbing brush were as necessary as antiseptics. Few surgeons
to-day employ antiseptic solutions in wounds unless the wound itself is
already infected, when it becomes necessary. In wounds which are clean
and made by the surgeon under aseptic conditions, no antiseptic drug
is required which may indeed be actually harmful, for these chemicals
which destroy germs are not altogether harmless to healthy tissue,
particularly when used in strong solution.
The discovery of anæsthesia and the promulgation of the germ theory
of inflammation, together with the subsequent perfection of the means
of destroying microbes, all within the memory of many now living,
have revolutionized surgery to such an extent that the surgeon
reaches fearlessly into regions which before were impracticable, and
undertakes operations which were never even dreamed of a generation
ago. One can readily imagine that no surgeon would care to undertake,
and no patient would endure, the agony of an operation lasting for
several hours without an anæsthetic; and that it must have been only
an immediate and certain danger of death that compelled a surgeon, in
pre-antiseptic days, to open an abdomen or brain when he realized the
great probability of subsequent inflammation and death.
Let us look at some of the individual advances of surgery since the
introduction of anæsthesia and of the use of germ-destroying agents,
considering first, simple fractures.
OF SIMPLE FRACTURES.—Anæsthesia was the means of permitting surgeons
to “set” fractures in a satisfactory manner and without pain; and the
use of antiseptics has prevented many of these fractures from becoming
compound fractures. Lately there has been a change in the general
treatment of fractures which is proving a great advancement. Formerly
it was the custom to keep not only the broken bone itself perfectly
quiet on a splint until union had taken place, but also to immobilize
all the neighboring structures, joints, muscles, and tendons. This
meant that when the limb was taken off the splint, not only would the
bone be “solid,” but there was also a tendency to fixation of the
muscles and joints, so that it took the patient as long to get back
the use of the limb as it did to unite the broken bone. This is now
obviated in many fractures by beginning both the passive and active
motion of the neighboring muscles and joints at a much earlier period
than heretofore; in fact, in many fractures, such as those near the
wrist, by never allowing these adjacent structures to get stiff at all,
but keeping up the passive motion (while the fragments are held firmly
together) from the very first dressing. In other more complicated
and serious fractures where motion is contra-indicated, the use of
carefully applied massage prevents largely the stiffness and the
wasting of the muscles which results from long confinement on splints.
COMPOUND FRACTURES.—In pre-antiseptic days compound fractures were one
of the greatest causes of the amputation of limbs; and yet, to-day,
these same breaks, which twenty-five years ago would have cost the
patient his limb, are, by means of antiseptics, rendered aseptic and
converted into a simple fracture by the closing of the wound, and the
part is not only saved but fully restored to function.
BONE DISEASES.—Diseases of the bones, as inflammation, caries, and
necrosis, are now dealt with very differently from of old. The diseased
structures are now thoroughly removed; and the inflammation which at
one time kept the patient in misery and danger for a long time is
subdued from the start.
OSTEOTOMY.—This term, which means the division of a bone, is generally
applied to the correction of deformities, such as bow-legs. This
operation fifty years ago was not frequently resorted to, and then
only in severe cases, the milder ones being left alone or treated with
braces, which at best could do little more than prevent increase in
deformity. When the operation was performed on the bone, it was then
divided, usually with a saw. The operation nowadays for this condition
is what is called subcutaneous osteotomy; that is, the wound made is
only as large as the chisel used for severing the bone, about one
half inch, and owing to our knowledge of microbes and our means of
destroying them and preventing their ravages, hundreds of legs are
made straight every year which a generation ago could not have been
safely touched.
[Illustration: CLINICAL AMPHITHEATRE. GARRETT MEMORIAL BUILDING,
PENNSYLVANIA HOSPITAL, PHILADELPHIA, PA.]
AMPUTATIONS.—The first successful amputation at the hip joint, for
either injury or disease, in the United States, was done in 1806 by
Dr. Brasheur; the next was not accomplished until 1824. As late as
1882, the great American surgeon, Gross, wrote in his “System of
Surgery:” “To no operation that can be performed on the human body is
the oft-repeated maxim, ‘_Ad extremos morbus extrema remedia_,’ more
justly applicable than to amputation at the hip joint. The operation
may become necessary both on account of disease and accident; but
it is of so formidable a nature and so fraught with danger, that it
should never be undertaken unless the patient has no other chance
of escape. The great risk which attends it is chiefly due to shock,
loss of blood, suppuration, erysipelas, and pyaemia.... Under highly
favorable circumstances, much of the enormous wound may unite by the
first intention; but, in general, more or less suppuration takes place,
and in some instances the discharge is so copious as to lead to fatal
exhaustion. The greatest danger of all, however, is the occurrence of
pyaemia, or secondary abscess, especially in amputations at the hip
joint in consequence of injury, as a compound fracture or a gunshot
wound.” This gives the attitude of the profession toward this operation
a little more than fifteen years ago, and the dangers which attended
its performance. Let us add that the mortality at this time may be
expressed in the following figures. (Dr. F. C. Sheppard prepared these
statistics for Dr. Ashhurst.) Of 613 cases in which the results are
known, “237 occurred in army practice, of which 30 recovered and 207,
or 87.3 per cent died; 71 were performed in civil life for injury, with
the result of 47 deaths, or a mortality of 66.1 per cent; 261 were
practiced for disease, with 105 deaths, or a mortality rate of 40.2 per
cent; and of 44 amputations for unknown causes 34, or 77.2 per cent
were fatal.”
In 1890, Dr. John A. Wyeth of New York introduced his “bloodless
method” of amputation at the hip joint, and he recently reports 69
operations performed after this manner by himself and others, in which
there were 11 deaths, 5 of which occurred in cases of extreme injury,
where the patients had lost a large amount of blood and vigor before
operation. In 40 cases the operation was done for malignant growth,
and 4 deaths occurred, 10 per cent. In 22 the amputation was made
for inflammatory disease of the bone, and 3 died, 13.6 per cent. One
has but to contrast these statistics to understand what antiseptic
methods and recent improvements in the control of hemorrhage have done
to lessen the mortality of amputations. The still more recent use of
salt solution injected into the circulation of patients suffering from
profuse hemorrhage has lately been the means of saving many lives
which would have otherwise succumbed to the loss of blood and the
shock subsequent to injury and operation. As illustrating the contrast
between the septic and antiseptic methods, let us consider the surgery
of our Civil War and compare with that of to-day, and we shall see the
enormous differences in methods, and particularly in economy of limbs
and organs as well as mortality.
[Illustration: PENNSYLVANIA HOSPITAL, PHILADELPHIA.]