within the past twenty-five years. The making of an aseptic wound
does away largely with the much dreaded secondary hemorrhage of a
generation ago, by preventing suppuration, which is usually the
cause of secondary hemorrhage. The clumsy and complicated apparatus
of former days for controlling hemorrhage has been superseded by the
use of the Esmarch rubber tourniquet, the neat hemostatic forceps,
and the sterile animal ligature. No surgeon thinks to-day of applying
a silk ligature to a blood vessel and allowing it to hang out of the
wound until it separates, so that in case of secondary bleeding he
could readily find the vessel; but he applies an absorbable ligature,
usually of catgut, which is sterile, and which is entirely absorbed by
the tissues after it has done its work. Much suffering has been saved
patients by the introduction of absorbable materials for ligation of
vessels and sewing of wounds. Formerly one of the great dreads of
wounds was the “taking out of the stitches.” To-day where the wounds
are not inflamed this is little complained of, and where the animal
suture is used there is no discomfort whatever. Many means have, during
the past century, been employed for the resuscitation of patients
suffering from profuse hemorrhage and shock. The idea of injecting
into the veins of the patient thus affected blood from another person
or from an animal is not new, and has at times been quite successful.
The most generally used method was to draw the blood from a healthy
person or animal and inject it into the vein of the patient with a
syringe: however, so-called “direct transfusion” was also employed,
and consisted in pumping the blood direct from the vein of the healthy
individual into that of the patient. Other materials than blood have
been injected into the blood vessels of persons suffering from great
loss of blood, notably milk. All of these methods have been put upon
the shelf, never to be called into use again. The ingenuity of the
nineteenth century suggested the substitution of a solution of common
salt for blood and, to-day, the intra-venous injection of normal salt
solution saves hundreds of lives. The solution is made to resemble
as closely as possible the liquid portion of the human blood (the
_liquor sanguinis_), especially as to specific gravity; and as it is
always sterilized by boiling before being used, it is free from all
the dangers which accompany the transfusion of one person’s blood into
another. No well-appointed operating room is without its transfusion
apparatus and its salt solution ready for use.
WOUNDS.—Reference to the remarks on asepsis and antisepsis will show
the reader that the treatment of wounds has undergone a complete change
in the past quarter of a century; but probably the modern treatment of
gunshot wounds illustrates this better than anything else. Until 1885,
only six cases were recorded where the abdominal cavity was opened
for gunshot wounds, but since that time hundreds of cases have been
treated in this way every year. The injuries were formerly considered
almost certainly fatal, and if the intestine was injured the patient
assuredly died. Now the abdomen is opened, hemorrhage controlled,
wounds—often to the number of six or eight or even thirty or more—of
the intestines closed, or an injured section of the intestines removed
and the abdominal cavity cleansed and closed, with many favorable
terminations to make the operation not only a justifiable one, but one
of necessity and safety. There is no comparison with the present-day
results of gunshot wounds of either abdomen or chest and those of a
generation ago. It is the duty of the surgeon, in case of gunshot wound
of abdomen, to open, explore, and repair, whereas formerly it was
considered the part of wisdom to leave the patient without radical
treatment and only to make him comfortable with opiates. Thus cases
of damage to the intestines and viscera did occasionally recover in
pre-antiseptic days, but it was the rarest occurrence.
What has been said of gunshot wounds applies also to stab wounds of the
chest and abdomen.
THE ALIMENTARY CANAL.—Probably the surgery of no portion of the body,
unless it be the brain, has been so much improved during the past
fifteen years as that of the alimentary canal. The esophagus or gullet
is now opened with impunity for both disease and injury. This organ is
not only approachable through the neck but also through the back part
of the chest, by resection of the ribs; and the latter operation is
frequently made necessary by the lodgment of foreign bodies,—buttons,
false teeth, etc.—so low down in the esophagus that they cannot be
reached through the mouth or through an opening made in the neck.
THE STOMACH.—This organ, which was formerly a forbidden field to the
surgeon, is now subjected to the most varied surgical operations,
from simple opening for the purpose of removing a foreign body or
establishing a fistulous tract to the resection of a portion of it
or to its complete resection, as has been successfully accomplished
several times within the past year or two for malignant disease. The
removal of the smaller end of the stomach for cancer is now a frequent
operation. During the war of the rebellion there were sixty-four cases
of wounds of the stomach, and only one recovered. In over six hundred
and fifty cases of wounds of the intestines there were recorded only
five cases of recovery from wounds of the small and fifty-nine from
wounds of the large intestine.
THE INTESTINAL TRACT.—What has been said of the stomach applies also
to this portion of the alimentary canal. No surgeon can nowadays call
himself such if he is incapable of removing a diseased portion of
intestine, it may be only a few inches or several feet, and bringing
the dividing ends of remaining intestine into such apposition that
healing takes place and the function is restored. Until recently, when
the means of anastomosing the intestinal canal were perfected, it was
the custom of the surgeon to bring the severed ends of the intestines
into the abdominal incision and suture them there, establishing in this
way an artificial anus with all its accompanying discomforts. This was
certainly better than allowing the patient to perish from his disease,
but how infinitely preferable is the present method of bringing the
healthy cut ends of the intestine into apposition and reëstablishing
the calibre. It is this operation which has so much reduced the
mortality of intra-abdominal injuries, gunshot wounds, stabs, etc., and
has made hundreds of sufferers from intestinal cancer either well again
or comfortable for years. The perfection of the operation of joining
one part of the alimentary canal to another has been due largely to the
ingenuity and perseverance of American surgeons, who have devoted years
to experimentation and practice upon the cadaver and upon animals.
THE KIDNEYS.—The kidney has not been behind the other organs of the
body in reaping the benefits of modern surgery. The first case of
removal of the kidney was done in 1869 by Simon, and was successful. It
was done only after a number of dogs were operated on successfully to
demonstrate that life and health are compatible with only one kidney.
Since this time the removal of a kidney for disease or injury, when its
fellow of the opposite side is healthy and performing its function, has
been looked upon as an entirely justifiable operation. The surgery of
this organ has lately so far advanced, however, that many kidneys are
now treated by more curative operations. In 1880 the first operation
was done for the removal of a stone from the kidney, an operation
which now nearly every surgeon of much experience has performed. The
operation for the fixation of a floating kidney, which is now so
common, was first done in 1881. Now, since Simon’s bold experiment the
lives of between two thousand and three thousand persons have been thus
saved who had otherwise certainly died.
THE BLADDER.—For generations the bladder has been considered a
legitimate field for surgery, but modern methods and technique have
greatly extended the domain. One of the greatest advances in bladder
surgery has been the crushing of stone and its immediate removal.
Until 1825 the treatment of all stones in the bladder was their
removal through an incision made in the organ. At that time Civiale
first performed the operation of passing a bladed instrument into the
bladder and crushing the stone, then allowing the patient to pass it
subsequently at urination. The operation became quite popular with
certain surgeons as early as the middle of the century. The cutting
operation has, however, never been entirely put aside, and even to-day
it is, in many cases, the best and only procedure. In 1878 Bigelow, of
Boston, devised the method which is now universally used, of crushing
the stone and washing it out at once through a silver tube. This was a
great stride ahead of the old method.
One of the great difficulties in deciding upon the removal of a kidney
has been the trouble of finding out whether the other kidney is doing
its work, and this Kelly, of Johns Hopkins University, has done much to
overcome in devising his method of examining by looking at the openings
of the tubes of the kidneys where they empty into the bladder. If the
kidney is performing its function the urine will be seen flowing from
its tube into the bladder.
HERNIA OR RUPTURE.—Probably the treatment of no condition has received
more consideration from the surgeon of the nineteenth century than that
of rupture, and it was not until 1891 that an operation was devised,
simultaneously by an Italian and an American surgeon, which has proved
for itself all that its originators claimed. Hundreds of operative
methods have been brought forward for the cure of this troublesome and
dangerous condition; but, until the operations of Halstead and Bossini
were brought forward, little prospect of an absolute cure could be
promised a patient, and the conservative surgeon would only undertake
to operate upon very troublesome cases such as could not be controlled
by a truss. Now nearly every case of hernia may be looked upon as
curable by an operation.
OPERATIVE GYNÆCOLOGY.—The operative treatment of the disease of the
female generative organs has been revolutionized in our century,
and its revolution has been largely due to American surgeons. The
first ovariotomy ever performed was done in Kentucky, by Dr. Ephraim
McDowell, in 1809. In the fifties, Marion Sims won great renown for
himself and his country by his wonderful ingenuity and boldness in
this line of work. The greatest advance here, as in all departments
of surgery, has been made since the introduction of antiseptic and
aseptic principles. To-day there is no disease or condition which, if
seen early enough, cannot be cured, or essentially relieved at the
hands of an expert abdominal surgeon. Thousands of women are now saved
every year by these means who formerly would have certainly died or
remained hopeless invalids.
APPENDICITIS.—This condition must seem to the ordinary reader to be
either a new disease or one much more prevalent than in days gone by,
but it is not the case. The cause of this appearance is the fact that
in former times the condition was not recognized in its incipiency, and
the exact cause of the trouble was unknown. The condition then advanced
until it was called typhlitis, peritonitis, and obstruction of the
bowels, etc., all of which would to-day occur if the conditions were
not recognized early and treatment immediately instituted before the
inflammation and infection extended from the appendix to neighboring
tissues.
BRAIN SURGERY.—This branch of surgery is practically a triumph of
recent years. Formerly the brain was never interfered with except
for injury (traumatic), and even then nothing was done excepting for
the removal of pressure, as from a piece of depressed bone, and the
institution of drainage. To-day the skull is opened for epilepsy;
abscesses of the brain are opened and drained successfully, and tumors
of the brain are removed, thus not only in numberless instances saving
life but—what is equally important—saving the usefulness of the
life and mind. The first actual successes in this line are recorded
by Bennett and Godlee in 1884, who localized and operated on and
ultimately found a tumor. The patient died, but the bold beginning
was followed by a number of other surgeons, till this new region for
exploration, hitherto untouched, has become a fertile ground for
successful efforts. Abscess of the brain, until twenty years ago, was
almost invariably fatal. MacEwen in 1879 located an abscess of the
brain and begged to be allowed to operate, but was refused by the
family of the patient. After the death of the patient he operated
precisely as he would have done in life, evacuated the pus and
demonstrated that had he been permitted to do so he could have saved
life.
Where the cranium is wounded surgeons nowadays will not hesitate to
open the skull, secure the bleeding vessels, remove clots, and thus
many lives are saved. Even comparatively slight injuries to the skull,
where the brain is damaged, involve oftentimes destruction to the
arteries and blood is effused, producing such destructive pressure
as causes very serious symptoms or even death. In other instances,
the results of a blow or a fall without injuring the skull may cause
profound damage and subsequent hemorrhage. In all these cases operative
interference, now extremely safe and easy, may readily save life.
Gunshot wounds of the brain are now only occasionally fatal, provided
opportunity offers for prompt and clean operative work. Even where the
ball has traversed the entire length of the cerebrum, recovery has
followed operation. The results of brain surgery in relieving certain
forms of epilepsy are occasionally most brilliant and frequently much
relief is afforded. Where the epilepsy is of the character known as
focal, and where there is evidence of irritation of the brain, due to
a local pressure, whether of the cranial walls or of some new growth
within the brain tissue, the removal of these sources of irritation
has in many reported instances been most satisfactory. Again,
certain cases of protracted headache, so severe as to render life
insupportable, have been cured by trepanning the skull. Certain forms
of insanity have been modified and relieved where this had followed
upon brain injuries. It is of great interest to reflect upon the
methods by which students of brain disease are enabled to determine so
exactly the location of tumors, abscesses, hemorrhages, clots, scars,
and other alterations of tissue giving rise to epilepsy and brain
disorders, and which afford no indication of the diseased locality
by any changed condition of the surface. In dealing with other parts
of the body, if the precise locality of the part to be operated on
cannot be at first determined, there is no hesitation in the minds of
the surgeons in cutting down upon, and searching for, that which he
proposes to remove. In dealing with so delicate an organ as the brain,
however, this cannot be permitted; for a variation of the very smallest
dimension will sometimes change the manipulations from those of perfect
safety to the most fatal results. Our knowledge of the location of
the functions of the brain and the areas from whence arise governing
influences has been derived almost solely from experiments upon living
animals. Among the names of the great pioneers in this direction must
be mentioned those of Ferrier and Horseley, of England; Fritsch,
Hitzig, and Goltz, of Germany. The researches which have thus opened
up a new realm of operative possibility are among the very greatest
triumphs in our means of saving life and affording opportunity for
relief of the most serious disablements known to modern times.
For illustration of how these studies are pursued, it may be of
interest to review the method used by Horseley.
The brain of a monkey having been exposed at the part to be
investigated, the poles of a battery are applied over squares one
twelfth of an inch in diameter, and all the various movements which
occur (if any) are minutely studied. One square having been studied,
the next is stimulated, and the results are again noted, and so on from
square to square. These movements are then tabulated. For example, all
those adjacent squares which, when stimulated, produce movements of
the thumb are called the region for representation of the thumb, or
“the thumb centre;” and to all those squares which produce movements
of the hand, the elbow, the shoulder, or the face, etc., are given
corresponding names. In this way the brain has been mapped out, region
by region, and the same minute, patient study given to each.
These animals are etherized so that they do not suffer the least pain.
Such operations, with few exceptions, even without ether, are not
painful. The brain itself can be handled, compressed, cut, or torn
without the least pain. A number of cases have already been reported
in which a considerable portion of the human brain has been removed by
operation, and the patients have been about their ordinary avocations
within a week or two.
Studying in this way the brain in the lower animals, it is now possible
to get a very fair knowledge of the localization of many of its
functions in man.
Moreover, portions of the body can be entirely severed, and, if
suitably preserved, can be replaced, and they will adhere and grow as
if nothing had happened. When a wound is slow in healing, we now take
bits of skin, either from the patient’s own body or provided by the
willing family or friends, or even from frogs, and “graft” them on the
surface of the wound. They usually adhere, and as enlargement takes
place at their margins, they coalesce by one half the time required for
healing. Even a large disk of bone, one or two inches in diameter, when
removed from the skull, can be so saved and utilized. It is placed in
a vessel filled with a warm antiseptic solution, which is again placed
in a basin of warm water, and it is the duty of a special assistant to
see that the thermometer in this basin shall always mark 100° to 105°
Fahr. The bone may be separated from the skull so long as one or two
hours, but if properly cared for can be replaced, and will grow fast
and fulfill its accustomed but interrupted duty of protecting the brain.
[Illustration: X-RAY PICTURE OF A COMPOUND FRACTURE AND DISLOCATION OF
THE FOREARM.]
RÖNTGEN RAYS.—One of the most recent advances in the art of surgery
is the discovery and use of the X-rays. In December, 1895, Professor
Röntgen, of Würzburg, announced his discovery, and since then its
utility has continually increased, until to-day no large hospital or
properly equipped teaching institution, indeed no first-rate surgeon,
is without the X-ray apparatus. By its use many doubtful cases of both
injury and disease in surgical practice are thus entirely rendered
clear. In the diagnosis and treatment of many fractures it is nearly
indispensable, showing the exact location of the break and the position
of the fragment before and after dressing. Probably in no other
condition, unless it be in fractured bones, has the X-ray proved itself
of so much value as in the location of foreign bodies lodged in any of
the organs or tissues of the body. Before Professor Röntgen’s discovery
it was not of infrequent occurrence that an exploratory operation was
necessary to positively prove the presence of a foreign body, and even
this was at times of necessity a failure. To-day the X-ray picture
enables the surgeon to learn the exact location of the foreign body and
indicates to him the best point from which it may be attacked. With
repeated improvements in apparatus the time of exposure required for
making the picture of the part has been greatly reduced. The advantage
of this was made manifest when it was discovered that destruction of
the skin, the so-called “X-ray burns,” might follow long and repeated
exposure to the rays. It is not always necessary to make a plate of
the part to be examined, since by simply studying the parts by the
eyes through the fluoroscope or the fluoroscopic screen the surgeon
can readily see everything that a photographic picture could show him.
The fluoroscope or screen is now often used during the operation of
removing foreign bodies; through it the surgeon can watch the various
steps of his operation, his approach to the foreign body and its final
removal.
[Illustration: X-RAY PICTURE OF A DISLOCATED ELBOW.]
If the field of its usefulness continues to expand at its present rate,
it will not be long before its use as a diagnostic measure will be as
valuable to the medical man as it now is to the surgeon.
By such instruments of precision as this, and others less conspicuous,
the old elements of intelligent inference and argument by analogy and
exclusion are rendered of less value, and a rapid approach is made to
scientific exactitude in surgery as well as medicine. All this has
attained a far higher quality and scope in the last quarter of this
century than in any other period of the world’s history, and we may
look to great advances in the coming century, in all life-conserving
and remedial measures whereby the race may enjoy a larger measure
of relief as well as immunity from the onslaught of disease and the
results of accident.
There is shown here for illustration a photographic picture of a
limb, taken by the X-ray now growing familiar to every one. It should
be borne in mind that while it is a simple matter for the casual
observer to note obvious solutions of continuity in bones, or the
presence of foreign bodies, this is not the chief item of usefulness
to the surgeon, and certainly not to the medical practitioner. A
special training is required to study and interpret the findings and
appearances of the tissues, their altered relationships, densities,
and many other matters entirely insignificant to the uneducated among
medical men or laity.
Again, the picture here shown is similar in outline to but a reversal
of the shading seen through the fluoroscope by direct vision, when the
greatest skill is required in noting the significance of altered states
in the denser or softer tissues.
When suits for malpractice are instituted against surgeons it is not to
be admitted that the evidence or findings of the “highly intelligent”
but not technically skilled witness can have the slightest weight as
proving the condition of tissues of which they are very ignorant, not
only physiologically but more so pathologically.
PROGRESS OF MEDICINE
BY FRANK C. HAMMOND, M.D.,
_Instructor in Gynecology, Jefferson Medical College, Philadelphia_.
“As a point of history pregnant with valuable deductions, it is good
to look back upon the conditions of medicine in former times and find
that it has always kept pace with the progress of the physical and
moral sciences. Where these, however, have been marked by folly and
credulity, medicine has exhibited the same imperfections.”
It is difficult to trace the improvement in successive eras, because
they melt into one another by indefinable gradations. During the
earliest period it was believed that physic was an art which was
supposed to be most mysterious, and it was presumed that the practicers
held communion with the world of spirits. The practice of medicine in
those days consisted in the usage of agents necessarily unreliable, as,
for instance, the word abracadabra hung around the neck as an amulet to
chase away the ague, etc.
Much time has been wasted in attempting to portray the first origin
of medicine. Bambilla, a surgeon of Vienna, has asserted that Tubal
Cain was the inventor of cauterizing instruments, apparatus for
reducing fractures, and other instruments for surgical procedures, thus
endeavoring to prove that surgery antedated medicine. It is evident
that medicine must have had a very early origin, for mankind even in
the earliest ages suffered pain and the train of sequences due to
exposure, and hence soon discovered a method of alleviation. Their
category probably consisted of herbs. Unacquainted, however, with the
construction and function of the human economy, practitioners were
unable to trace the progress of disease, and the more fatal internal
maladies were ascribed to the deities whom they feared. Hence, various
superstitious practices would arise and be handed down from one
generation to another. We may imagine this to have been the origin of
the healing art, and such is nearly its present condition amongst the
savages of Africa, Australasia, Polynesia, Sumatra, etc.
Later on, the priests became the physicians, from being the oracles of
the divinity whom the people wished to consult. The various remedies
were handed down from one to another, as medical science did not
exist at that time. Herodotus informs us that even in his time the
Babylonians, Chaldeans, and other nations had no physicians. When any
one was attacked with disease the patient was carried into the public
street, and passers-by who had suffered from a similar affection, or
nursed one who had, advised the sufferer to employ the measures that
proved successful in former cases.
The earliest writers on medicine trace its origin, in common with
that of most other branches of knowledge, to the Egyptians. They
appear to be the first nation that cultivated medicine and furthered
its progress. Many peculiar medical properties were attributed to
the deities. All diseases were supposed to originate from the anger
of Isis. Resin was burned in the morning, myrrh at noon, and a
composition termed cyphy in the evening, in the temples of Isis, and
the sick were taken there to sleep, during which the oracles might
reveal to them the means which they should employ to effect a cure.
This is an illustration of the superstitions which prevailed at that
time.