THE CENTURY’S ADVANCE IN SURGERY
By J. MADISON TAYLOR, M.D., and J. H. GIBBON, M.D.,
Surgeon in Pennsylvania and Children’s Hospitals.
At the Dawn of the Century.—In the year 1579 the celebrated French 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.
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.