The Progress of the Century

by Unknown

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.