Modern Surgery.

Evening Post, Volume LXIX, Issue 118, 20 May 1905, Page 15

Modern Surgery.

(By Samuel Hopkins Adams, in M'Cluro's Maga/iino for March.) Surgery is the most modern of sciences. Up to within twenty years it had boon, in tho main, tho last expedient of desperate needs, or tho uUeviunb of miuor or Bi|rfauo ailments. In its oxtwordiiiary recent development it has oxtended Its f>copo to ovory organ in the human body, not only for radical operations, but for the relief of conditions formerly believed to bu beyond aid. Of tho major operations now fearlessly undertaken every day 90 per cont. would have been considered by the surgeon of the last generation extremely hazardous, if not qclually murderous. To two great medical devices tho possibility of surgical advance must bo ascribed ; anaesthetic*, discovered in tho late forties, by Morton, of Hartford,, and Simpson, of Edinburgh, independently, which, with their inestimable bio&sing of insensibility, vastly broadened tho range of practicable operations ; and antiseptics, discovered by Pasteur and applied to surgery in tho early seventies by Sir Joseph Lister, which reduced the danger ot blood-poisoning, tho operator's deadliest foo, to a comparatively small consideration. Ono instance in each cuse will serve to illustrate. In tho wars preceding tho middle of tho last century, before anaesthetics had como into gener.il use, thousands of wounded men, operated upon with a bulle(< between their teeth to bitp on, succumbed to sheer agony and shock. Other tliou-iands died as "inoperable cases," because, in their weakened condition, tho torture of the knife would huvo been fatal before tho ordeal could be finished. Before the use of antisoptics, an ordinary compound fracture of the arm or log, whore tho bone was exposed to tho infection of the outer air, resulted in death from bloodpoisoning in more than 60 per cent, of cases. That is, a compound fracture was more deadly than cholera, and about as fatal us (he bubonic pluguc. To-day, under tho best hospital conditions, iliis mortality has been reduced to one seventh of ono per cent. THE Jity A OF ENTHUSIASM. Under tho influence of these discoveries a tremendous impetus was givon to iho science Unbridled enthusiasm for the now worlds thrown open to their conquering progress, carried tho great body of surgeons too far. They operated wherever oporation was remotely indicated, and, in many cases, whero it waHi't indicated at all. Where, 12 or 16 years ago, tho operator carried away with him a diseased organ, or all of it that ho could get, to-day he excises the diKcuite instead of the organ, performing nut as much as he may, but as little as ho can This is tho totichslono of modern surgery : to savo not lffn alone, but tho structure of the human body. Its watchwoid is conservation. THE ORDEAL OF A PIONEER. It is in tho abdominal region that surgery has been most triumphant. In fact, this brunch may fairly bo regarded as a eomploleAl science, although certain details will doubtless bo worked out to greater peifection. A century age there was no such thing as abdominal operating. Such use of the knifo would have been regarded an madness. Stomach and intestinal troubles and uilmcius of the principal organs were for ''physic," and physic of a sort which our generation happily knows not-. ' T|io pioneer \>.i!> Dr. liphraim MDowell, of Dunsvillej lycntueky, who. determined to operate, upon a Mrs. Crawford for ovarian tumor. Other physicians denounced his plan as murderous, and raised the people against him, On tho day of tho operation a mob gathered ouUida the woman's windows, carrying guns und ropes, and M'Dowelj operated with thoir threats ringing in his cars Had tho patient died he would probibly have been .lynched. She lived. Two other similar operations weie sue ccsaful. Then camo ' tho reward of tins pioneer. PriMs, pulpit, and — bitterest at all— 'his own profession attacked M'Dowoll «|id his methods, with a degreo of itavagory unparalleled outside o: religious oontroveifiy. Hut ovariotomy was utubli'jhed, and it spread, though slowly. The years of life saved to tho women of AuiM-ica by M'DoK'cll'a couraga and skill alone may bo reckoned in the tons of thoutmnds. But (hero is another nnd darker side. Reckless operators removed ovaries wholesale, often for unimpoilant or curable ailments, and the victims of their zeal billed tho hospitals, or, Morse, tho insane asvliuns. Those were not tho leaders of the profession, so much us the younger and less practised mon, possessing more ambition than knowledge, Conservative mirjjpry finally inlorposcdj and won its first important; triumph in this department, probably because in no other brunah were the evjls of radical surgery so terribly in evidence. "Operate only where you are certain ; cut out the disease, not the organ." THE CONQUERING OF APPENDICITIS. With tho establishment of ovariotomy, tho superstitition that it was fatal to cut into the abdominal cavity was exploded. Tentatively, und with occasional success, tho moro during surgeons essayed operations upon the Hvor, the kidneys, tho stomach, intestines, and othor organs of tho abdomen. But, until recent years, such practices were cohsidered justified only as a last resort, in cases of extronio necessity. How there is no organ jn thu abdominal cavity that is not daily oxplorod. Perhaps the most notablo success is in appendicitis. Twenty years ago tho sufTeror from appendicitis died—by another name, preferably (<inllammiition of tho bowols" or "peritonitis." To-day tho d,eath-rato in tho best- ( equipppd hospitals is not 2 per cent. For years after the Ttscript ion of the disease to tho troublesome little sne, whoso useful function has boon entirely superseded in the processes of evolution, it whs supposed that tho cause of it all was somo such foreign substance ns a grape or lemon seed entering tho vermiform oppendlx. Occasionally the explorer with tho knife will find something in the appendix that doesn't belong there (a latent case produced a lump of solder from (mimed tomatoes), but this i» tho ruro exception. Appendicitis is canned by tho development of bacteria in the sac, usually associated with inactivity of tho intestine, 'liicorelicully tho operation is as simple a* dicing a pearl out of an oyster. An InoWon, a stroke of tho knife, a careful sterilisation, a suture to cl n*o the intestine., a dressing qf the wound — and it's all over in 20 or 30 minuter. More than half tho time it happens that way. The other cases prosent so wide a range of circumstances us to mako this operation Hio most interesting and variuhlo known. About onco out of five times the appendix, instead of being «t the front of tho intestines and easily get-at-able, aa it ought to bo, is somewhere olso. Then tho practitioner begins his search. Ho may locato it two or three inches from tho normal position, or ho may find it far around behind, or ho may discover it anywhcro between; sometimes ho misses it entiioly. Even whero it is, normally placed, ib often presents great difficulties, ft may be so far destroyed that tho surgeon must leave what rumuins of it, nnd devote his attention to draining the in. testinal abscew which has resulted. Or it may be so deeply involved that it caunpt bo sftfely cut out, but oftn only bo relieved of Its poisonous matter. Or it may have burst and scattered its con-

tents through the abdominal cavity, in which ease tho method is to clean and disinfect the w hole, area, in tho hope not a, veiy strong one— of wurdiug off peritonitis. For it is these cases which form tho death-rale, and it is for this reason that timely operations for appendicitis are s>o important. A diseased appendix, diagnosed early, can bo removed with practical assurance of complete success. REDUCING AN INSANE ASYLUM «V SURGERY. Another very common operation is for abscess of tho gallbladder or liver. Until within 10 years such abscebsos were opened and drained, n slow and tedious process, attended often with fatal results from exhaustion. Tho modern method is to remove tho cause, htones in tho bladder, which is accomplished with small mortality. Occasionally these stones aro as largo as a goose-egg. Sometimes tho small ones aro found in great numbers, moro than a thousand having been taken from the late Chief Justice Marshall. As a relief to human suffering this operation ranks next to ovariotomy. 15cforo it was practised many sufferers wero driven to suicide by tho pain caused by those calculi ; and in every asylum there wero inmates whoso melancliolia aroso from this disease. It is said that, shortly after tho establishment of tho operation, a visiting surgeon to an insane asylum released moro than 30 per cent, of tho women victims of melancholia, by removing tho source of their suffering. As in the case of ovariotomy, the medical profession ( united in declaring that the proposition to cut stones out of the gallbladder was tho tlicoty of a. butcher — until it wtis buecessfully achioved. WHAT SURGERY DOES TO TIIE HUMAN STOMACH. Tho stomaoh proper has ceased to be a serious problem to tho surgeon. Ho can invado and explore it with impunity. Ho can even, if circumstances demand, rcliove tho owner of it entirely, and so arrange the loose ends that the functions of nutrition aro successfully maintained. To be sure, tho patient can never thereafter derive much pleasure from his meals ; ho must restrict himself to a rigid diet; but for all tho other affairs of lifo ho may bo as competent as before. There arc to-day several stomachmen who arc earning their daily pro-digested ration in occupations varying from clerk to oxpressman. ANTISEPTIC SURGERY OF THE AllDOMINAL ORGANS. Before the discovery of anitscptics, op. orations upon the intestines were practically hopeless, as blood-poisoning froi)i the action oT the colon bacillus always present in the intestine, almost invariably followed. For somo years after the usij of antiseptics, intestinal hurgery was veil, turod upon only when thero was no other chanco of life. Doctors wero helploss in cases of perforation. "If you want to\ kill your man wire," wan a Western desperado's counsel,, "don't shoot at his head or his heart ; shoot at his belly." Sound advice up to tho middle eighties, when Dr. William T. Hull was the visiting surgeon at tho Chambeisi street Ilonpit-.il, New York city. Suvcr.il slums delivered tho products of debate to this institution, and Dr. Hull had unusual oppoi (unities for studying bullet and knife wounds from 'lungshoie and tho Italian quartern In a few isolated 1 cases hitherto, petfor.Ulom of the inttv ' tines had been sewed up, usually withj out success. Dr. Hull decided to try it ! systematically He found that c*c< I which weren't opi/inted on all died, ii«ual- | I.V of peiitoniliH caused by the leiikiftc j of the bowels into the /ib<!*omii)iil cuvify. I So ho opened up tho cavity, w.u>hed 'ii | out u itu sterilised water, and Mewe.d up the intestine. Tho Hist eY.sv recovered The second died. The thiid died Nnmti of Dr, Hulls associtto*. heciuic discouiaged. Hut he kept on, Jiul pieheutly the. hospital records showed a mortality io- , duced fiom nearly 100 per cent, lo below j6O per cent, bitoudilj the mortality hax , dcclingd, until now, in this ilahs of owes, some hospitals bhow a nito of only 26 per cent. Like the stomach, the kidneys aro practically, a wJved problem, biirgieally speaking, Formerly thoy were regarded with the sumo awo (is llio heart, bo far us major oporating is couo«rnou. Thu fcufferer' froni stone, ulcer, or tumor in tho kidney was left to d.io. Then it was fouua that where ono kidney was removed, tho other would Moulder tho extra working, and for a time the laboratories wero enriched by large accessions of thqsu u&eful organs. Hero again conservative surgery called a half. Nowadays tho surgeon knows that tho patient van get along better without tho disease than without his kldncy'.-'Tho stone, ulcer, or wha|; pot is removed, and tho qrgan left. Mortrt|ity, 10 per cent.— a ■ considerable reduotion from tho former 100 per cent. AMONG THE MYSTERIES, OF THE ' BRAIN. American brain surgery started in « Massachusetts atono quarry. An lri*h labourer, jamming' a crowbar into a bob where pnrt of a cjiarge of dynamite was lying in wait, produced the |o.gjc,il result, the orovtbar entering the head at the side, of the jaw anrt- projecting a foot out beyond tho vault 61 tho skull. The foreman notified tho coroner; some ono eleo sent for a doctor. The doctor got thero first, removed the crowbar, and took tho patient to tho hospitnl, I uhcre, to the annuoniont of the entire profession, the man recovered. Up to j that time tho brimi substance had been I regarded as prohibited territory, but, ths doctors reasoned, surely a surgeon's knife can go where a one-inch croubnr can pawi without fatal results. I '-Tho golden age of brain surgery seemICd dawning. It was a false hopo. Thero are few practitioners of this specialty, I think, who would ba willing, for tho honour of thtir profeciion, to have tlio history of the following decado of experimentation frankly related. Insanity, 1 idiocy, and death wero the results which i brought tho adventurous opeiatois to , their hotter senses and to this conclusion ; i that tho cerebellum, or lowor. lobo of the ] brain, in which lio tho nervo centres, i can never be touchod by the knife with impunity, nnd that only as the lust hope and on the surest diagnosis should the knifo be used there. For, ' even though the operator, pushing holdly in where, to quote Sir Astley Cooper, "thero is only tho thinness of paper between oteniily and his instrument," ovades adroitly tho inflniloly delicate mechanism that controls life itself ; even though his completed task bo followed by no hemorrhage, as is usually tho fatal case ; yot such is the nature of the. substance on which ho operates, that the scar ho leaves is. in itself hardly less baneful than tho eiadicated injury. Surgery of i the cerebellum has hardly roho beyond diagnosis. Wonderful indeed is this diagnosis, which traces a sensation at tho finger-tip, along the infinitely diversified telegraph system of the nerves, to its destination in the recesses of tho brain ; or refers the qudden twitching of a toetnusr.le to stimulation of some exactly defined portion of tho cerebral apparatus But, exVupl fti the cane of a few maladies like epilepsy, or injuiion producing removable procure from without upon tho brain substance it indicates no cine", 'J he area of knowledge is small, tho area of ignorance great, and the beht men doro prophesy no radical progress. LONG DISTANCE OPERATING. With the surroundings of the brain proper it is not „ Hero we see remarkable achievements, some of them

in opeiations performed half a body's length from the diMinbi>d organ. )letweon tho brain power and its lining is a shallow .se.i of lluid which extends all tho way down the hollow inside of the spine, around tho spinal cord. 11 this lluid becomes deranged or computed tho brain is directed. Now, in ono part of tho head this liquid .substance cunMiliites a littlo spirit-level, like a caponier':) level, which herves to keep the human machino properly balanced. Soiiiuliines the fluid in this level increases beyond tho normal capacity. Thou the patimit is annoyed by constant ringing in the ears, and prehontly becomes subject to severe and dangerous vertigo. This is because thu unconscious sen^i; of balance is disturbed. A few years ago the nicilitcul faculty were nt a loss for a erne. 3s r ow they know that the brain Hinds may bo controlled from the .spine. So they t&P tho victim of the deranged spirit-level near tho base of the hpine, draw off tho surplus fluid, and sfencl him on his way, relieved, balanced, and rejoicing. This lumber tapping promises to bo tho moat important advance yet made in tho department of tho brain, for not only is it employed in relieving and diving "certain brain ailments, but it is of inestimable value in the diagnosing of meningitis, abscesses, and other cerebral diseases; the. examination of tho lluid drawn from tho spine, in fact, affording diagnosis for all brain diseases other than the purely nervous ulFcctions. Tho dura mater, or outer lining of the brain, which encloses this llui*, is susceptible to various operations, tho chief one being for Jaclchonian epilepsy, which is caused by the pressure of tho lining down upon the brain, usually from somo injury affecting tho skull. Tiephining for epilepsy hardly has place in a consideration of modern surgery, since it is oldor than the records of mankind,' Trephined skulls of prehistoric periods have been found , the only change is improvement in diagnosis and in technical skill. In tho region of tho ear, a number of important cerebral operations have recently been devised, biich a- opening tho veins that drain tho brain to ivhevo inHumiliation (a process, until recently, considered fatal) and draining brain abscesses through tho car cavity. In fact, the whole tendency of late has been to reach tho corebulluni through the mnstoid cavity back of tho ear, rather than by cutting through the bkull. DR. LOKISNZ ANJ) THE AMERICAN ORTHOPEDISTS. Orthopedic science received a decided impetus in -America from the visit of tho famous Dr Lorcnz, of Vienna, last j»>ar. ttis operations for the relief of congenital dislocation of the hip joint by manipulation, transferred to the category of operable diseases a malady hitherto set down 08 hopeless. Not all of his operations wore successful, but many uf tlu-m weio. His method cdX for no surgical instrument ; only his wonderful hands, comparable, so an anatomist tells mo, to no others except the hands of the steelsinewed l'aderowski. Exerting bin phenomenal muscular power, l.oren/. kneads and strelclns the hip until muwlos, ligaments, and arteries are gradually elongated j then, with a final elfort, he draws forward the displaced joint nnd it re- ! tracts into the socket. For hi* HraM'x- ; position in America, at the New York 1 Hospital for tho Ruptured »nd Oripple-i, Dis Oibney and Whitman, peihapa this , most eminent American oiUuijvdK specialism, pitM-riled an eight year-old child from one of the wards. The child , wim rtht-rispd and pKwwd upon the t thlc, 1 and Dr>. Lqi\ n/< b<\4".»«i talking il * »c i worked. He. hcmiunl to o.\ort u<> xprtwl • etl'orC, yet, tit'th" out of live imnutoh , there "«•} ft diMinft UK. and tinphynki.nA pres-nt Incke into uppliUM1 Tluiy re(.i>j4iiis«'d the .viand as tho snaping "of the bone into jil.ice. MAKINfi 'I HE HALT TO WALK. For tho relief of club-finilod ehildnii mime ivniink ible e\pedunts Im\o Imi dtviM'd in tciuion ti.'implMit Uu.ii. t'lub- • foot is cuisi-d by p.ir;ily«li of th« li>U.M'i> 'i j on ono side of "the ku, while t>»" other jis normal. Now, every p. mm ban nn^ie i muiiles leading to the foot than lie i actually Heeds Thflt it, if we were depiived of the teudonti eniblliu; v-> to wriggle our tins., we ?hon'd :-ttll be ;»bli to rl'iake a living, and would not even Ha ' depiiV'^l »>f mnn^ of thi- |iliM«nia<* of lite. On this piinciplu the surgeon t--ikes his club-fouled V!llV !ll ' cill i lllts l ' ull ' l ' n °' tUi) tendons which can b.i spiired ftom tho ! normal side, of the foot, ruiries th«m I nrnund the lei, and unites Ilium to the 1 dead mua.'lr-!. with v length of .sii"u cord. Soon tho foot usiumes its norm.al i.hnpe, and though it. is never quite ns good ,ts an ordinary foot, it irniwfmmt a pitiful cripple into a sound, healthy ehjhl with nothing worst; than a fcliffht limp. More ni'licil th-n tlio Iriuibptorrting of tendons is the grafting of m«rves for infiintile palsy, the diceiuo which causes a majority of tho world's cripples. Ib in yet too eaily to predict Success for this, but a veiy remarkable case if contuirwl in the retent records of tlio l'hiladelphia Polyclinic Hospital. The subject was a four-year-old girl. Examination showed that tho nerve controlling tho movements of the fool, which forks jttbt below tho knee, was dead. Tho operator exposed tlm dc.yd branch, clipped it off close to the main stem, opened a patch to the corresponding nerve brunch on the opposite side of the leg, and spliced tho' dead nerve into tho living. A month later tho plaster of l'ai'is cast was removed from the limb, and tho foot, wh'.,'h wiw' helpless bofore, moved lat the owner's control. Should the proi miso of this operation bo verified in other cases, results of incalculable value in the j relief of Buffering may foe looked for: