Special Operations
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.
W. W. Keen.