Another direction in which the century has seen enormous progress is in the introduction of instruments of precision. When I was a student in the early 60’s, instruction in microscopy was conspicuous only by its absence from our medical curriculum. Now every student who graduates is more or less of an accomplished microscopist, and carries into his practice the methods and observations which the microscope furnishes. At the same period I remember being greatly interested in a discussion which two of my teachers had as to whether it was possible to make an application accurately to the vocal chords in the larynx. Now every tyro in medicine makes such applications to the larynx as a routine procedure in cases requiring it, and similar methods have been applied by the ophthalmoscope to examine the interior of the eye; the rhinoscope, to examine the interior of the nose; the otoscope, for examination of the ear; and other similar instruments for examining all the other hollow organs in the body. If I add to these the hypodermatic syringe; the aspirator, which may be described as a large hypodermatic syringe for suction instead of injection; the clinical thermometer, which was introduced in the late 60’s; the hemostatic forceps, for controlling hemorrhage by seizing the blood-vessels and clamping them till we have time to tie them; and other instruments intended to facilitate our operative methods, it will be seen at once that the armamentarium of the modern surgeon is very different from that of his predecessor at the beginning, or even at the middle, of the century.
THE RÖNTGEN RAY
One of those extraordinary discoveries which startle the whole world came nearly at the end of the nineteenth century, in the winter of 1895–96. At that time a modest professor in the University of Würzburg announced that he could readily see the skeleton inside the body through the flesh! Naturally, the first announcement was received with almost absolute incredulity; but very soon his discovery was confirmed from all sides, and it has now taken its place among the recognized phenomena of science. By means of certain rays, which, being of unknown nature, were called “X”-rays, after the well-known mathematical X, or unknown quantity, Professor Röntgen has shown us that not only can the bones be seen, but that almost every substance in the body can be seen and reproduced in pictures. The reason for this is because they are all obstacles to the passage of these X-rays and so produce shadows on a sensitized photographic plate. If the exposure is sufficiently prolonged the rays penetrate even through the bones and act upon the photographic plate, so that no shadow remains. If the rays are allowed to penetrate for a shorter time the bones show dense shadows, and one can get a light shadow of the soft parts. If the exposure is still shorter, then we can recognize the dense shadow of the bone, the much less dense shadows of the muscles, and the still lighter shadows of the layer of fat immediately under the skin. The heart can be seen beating, and its shadow is now a well-recognized feature in skiagraphs of the chest. At first it was thought impossible to discover anything inside the bony skull, but there are now on record nearly a score of instances in which bullets have been detected within the skull, and after trephining have been found and removed exactly at the location indicated. It is a very common thing now to locate a piece of steel or other similar foreign bodies within the eyeball by the method of Dr. Sweet, or some similar method, within one or two millimetres (a millimetre is one-twenty-fifth of an inch). It is now well recognized that even stones in the kidney will throw shadows sufficiently strong for them to be recognized, and by noting their level in relation to the vertebræ we can tell precisely in what part of the kidney to make the incision in order to find and remove them. It has happened to myself and many other surgeons in the past to cut down upon a kidney, believing that there was a stone in the kidney, only to find that we had been misled by the apparently clear symptoms of such a foreign body. In future no such mistake should be made by any surgeon within reach of a skilful skiagrapher. Unfortunately, gall stones and numerous other foreign bodies, vegetable substances such as beans, corn, wood, etc., being as transparent to the X-rays as are the soft parts, are not revealed by means of this new method of investigation; but cavities in the lung, abscesses in bone, and similar diseases which produce thinning of the lung, bone, and other such organs, and so lighten instead of deepen the shadows, can now be recognized by means of light spots in the pictures as well as others by means of a shadow.
I spoke a moment ago of the need of a “skilful” skiagrapher, for it must be remembered that there may be the same difference in the personal skill, and, therefore, in the reliability of the results in skiagraphy as there is in photography. A poor photographer will get very different results from a skilful one, even if he uses precisely the same quality of plates and precisely the same camera. Personal skill and experience in the skiagrapher is, therefore, one of the most important elements in success. It must be remembered also that the X-rays in not a few cases may mislead us. I have, personally, fractured a bone on account of deformity, taken an X-ray picture immediately after the operation, the picture showing not the slightest evidence of a fracture, which I absolutely knew existed. Moreover, foreign bodies found on the outside of the person may mislead us, as, for example, the metal part of suspenders, a coin in one’s pocket, and such like. They look in the picture as if they were inside rather than outside the body, and any article the shape or size of which would not reveal its nature might easily be mistaken for a foreign body within the patient. Therefore, in many cases only an expert can determine precisely what the skiagraph means. I especially mention this, because there is a tendency at present to utilize skiagraphs in court in order to convince the jury that such a picture is an evidence of malpractice. Such pictures always need an interpreter in order to judge correctly of their meaning. It is precisely as if the jury were asked to look through a microscope. I have been myself accustomed to use the microscope for thirty years, but there are many instances even yet in which I am obliged to ask a pathologist or bacteriologist what I really am looking at in the microscope. While one may make a mistake of small moment in some cases, yet if a man’s life or liberty or purse is at the mercy of a jury which does not know how to interpret a skiagraph, and, may, therefore, give a verdict which is “precisely wrong,” as Professor Lincoln, my old teacher of Latin, used to call many of our translations, it will be a very serious matter and lead to gross injustice.
CITY AND VILLAGE HOSPITALS
Another great improvement in our means of caring for our surgical patients is the establishment of hospitals all over the land. These, happily, are not limited to our great cities, but in every country town and not a few large villages small but well-equipped and well-managed hospitals have been established which have done incalculable good. It is not too much to say that every city or town establishing such a hospital is repaid a hundredfold.
TRAINED NURSES
The trained nurse has fortunately come to stay. In fact, our antiseptic methods as above described have made the trained nurse indispensable. The old nurse, who, by many clumsy experiments on her patients, had obtained a certain rule-of-thumb knowledge of the care of the sick, can no longer assist in a surgical operation or properly care for any surgical patient. The modern nurse must of necessity be a well-educated, well-trained woman, knowing thoroughly modern antiseptic methods, and on the alert to observe every symptom of improvement and every signal of danger.
Without a well-trained nurse it is impossible at the present day properly to care for any serious surgical case, and I gladly bear witness to the intelligence, fidelity, and skill of scores of nurses who have assisted me, and without whom I should have felt as one blade of a scissors without its fellow.