The Progress of the Century

by Unknown

Surgery of the Chest and Heart.—The chest is the region of the body which has shown the least progress of all, and yet even here the progress is very marked. When, as a result of pleurisy, fluid accumulates on one side of the chest, even displacing the heart, we now do not hesitate to remove an inch or two of one or more ribs and thoroughly drain the cavity, with not only a reasonable, but in a majority of cases, one may almost say, a certain, prospect of cure. We have also entered upon the road which will lead us in time to a secure surgery of the lung itself. A few cases of abscess, of serious gun-shot wound, attended by otherwise fatal hemorrhage, and even of tubercular cavities in the lungs have been successfully dealt with, but the twentieth century will see, I have no doubt, brilliant results in thoracic surgery.

One of the most striking injuries of the chest has recently assumed a new importance, viz., wounds of the heart itself. In several instances an opening has been made in the bony and muscular walls of the chest, and a wound of the heart itself has been sewed up. The number is as yet small, but there have been several recoveries, which lead us to believe that here, too, the limits of surgery have by no means been reached.

Surgery of the Abdomen.—Of the abdomen and the pelvis a very different story can be told. These cavities might almost be called the playground of the surgeon, and the remarkable results which have been obtained warrant us in believing that even greater results are in store for us in the future.

In the earlier part of this article I spoke of the advantages of the study of the pathological anatomy or the diseased condition of individual organs. Perhaps no better illustration of the value of this can be given than in the studies of appendicitis. This operation has been one of the contributions to the surgery of the world in which America has been foremost. While there were one or two earlier papers, Willard Parker, of New York, in 1867, first made the profession listen to him when he urged that abscesses appearing above the right groin should be operated on and the patient’s life saved. But it was not until Fitz, of Boston, in 1888, published his paper, in which he pointed out, as a result of a study of a series of post-mortem examinations of persons dying from such an abscess above the right groin, that the appendix was the seat of the trouble, that this so frequent disease was rightly understood and rightly treated.

As a result of the facts gathered in his paper, the treatment was perfectly clear, not only that we ought to operate in cases of abscess, but that in the case of patients suffering from two or more attacks, and often from even one attack of appendicitis, the appendix should be removed to prevent such abscess.

The mortality in cases in which such an abscess has formed is, perhaps, quite twenty or twenty-five per cent., whereas, if patients are operated on “in the interval,” that is to say, between attacks, when the abdominal cavity is free from pus, the mortality is scarcely more than two or three per cent., and may be even less than that.

Surgeons are often asked whether appendicitis is not a fad, and whether our grandfathers ever had appendicitis, etc. As a matter of fact, in my early professional days, appendicitis was well known. It was called “localized peritonitis” or localized “abscess,” but while the disease was very frequent, its relation to the appendix was not recognized until from his study of its pathology an American pointed it out. Even now European surgeons, with a few exceptions, are not alive to the need for operation in such cases.

There is little doubt that the great prevalence of grippe during the last few years has increased the number of cases of appendicitis, both of them being catarrhal conditions of the lining membrane of the same continuous tract of the lungs, the mouth, the stomach, and the intestines.

One of the most fatal accidents that can befall a patient is to have an ulcer of the stomach perforate so that the contents of the stomach escape into the general abdominal cavity. Until 1885 no one ventured to operate in such a case. In an inaugural dissertation by Tinker, of Philadelphia, two hundred and thirty-two cases of such perforating ulcers of the stomach were reported, of which one hundred and twenty-three recovered, a mortality of 48.81 per cent. In not a few of them, if prompt instead of late surgical help had been invoked, a very different result would have been reported. If no operation had been done, the mortality would have been one hundred per cent.

In cancer of the stomach itself we are able, as a rule, to make a positive diagnosis only when a perceptible tumor is found. By that time so many adhesions have formed, and the infection has involved the neighboring glands to such an extent, that it is impossible to remove the tumor, but the statistics even here are not without encouragement, at least for comfort if not for life. In many cases the tumor has been removed and the stomach and intestine joined together by various devices, and the mortality, which is necessarily great, has been reduced by Czerny to twelve per cent. and by Carle to seven per cent. Even the entire stomach has been removed in several cases, and recovery has followed in about one-half. Most of these patients, however, have died from a return of the disease.