One of the most important advances has been madein 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 nowno 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 speakin 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.