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The physician can cure the sick, but he cannot cure the dead.-Chinese.
On Some of the Limits of the Art of Surgery.
Delivered at the Forty-Seventh Annual Meeting of the American
BY N. SENN, M. D., PH. D., LL. D. Professor of Practice of Surgery and Clinical Surgery in Rush Medical College; Attending Surgeon Presbyterian Hospital; Surgeon-in-Chief St. Joseph's Hospital.
Mr. President and Members of the American Medical Association:-Modern surgery has attained a degree of development which entitles it to the distinction of a science and an art. As a science, surgery is of recent date, having been founded and perfected during the last half of the present century. As an art, it has been practiced for centuries by our ancestors with credit to themselves and benefit to the injured, the crippled and the sick. When Boyer wrote the introduction to his classic work on surgery he expressed the conviction that surgery had reached perfection. How little did he dream of the great changes that would be brought in the practice of his cherished profession by the progressive pathologists and surgeons of the next few generations! How innocent and absurd does such statement appear in the face of the labors of such men as Virchow, Rokitansky, Rindfleisch, Klebs, Recklinghausen, in pathology; Pasteur, Koch, Ogsten, Rosenbach, Baumgarten, in bacteriology; Lister, Langenbeck, Billroth, Hueter, Esmarch, Czerny, Gussenbauer, Nelaton, Verneuil, Terrier, Macewen, Gross, Agnew, in surgery: Terrier, H Horsley, in cerebral localization; Spencer, Wells, Keith, Winckel, Martin, Péan, Ségond, Pozzi, Sims, Emmet, Battey, in gynecology, and a host of other faithful, unselfish workers who have made surgery what it is to-day and what it is intended to be-the most honored, respected and beneficent branch of the healing art. What a contrast between the standing of the surgeon of to-day in the community, the profession and from a scientific aspect as compared with his colleagues of only a century ago! It is not long since the art of surgery was limited to bleeding, cupping, leeching. setting of a broken limb, reducing a dislocation, stanching hemorrhage, opening an abscess or amputating a limb for injury or disease beyond the reach of conservative He was the subordinate, almost slave, of the pompous, arrogant and self-confident physician of that time. He subsisted from the crumbs that fell from time to time from his master's table. The betterment in the standing and sphere of the members of the surgical craft during the last century is entirely due to the enormous progress that has been made in the science and art of surgery.
During this time the legitimate field of medicine has gradually diminished before the advancing columns of progressive and aggressive surgeons. The physician no longer has a monopoly over the diseases of all the internal organs. The physician's distinctive apparel and gold-headed cane of but few years ago no longer intimidate the surgeon; they have disappeared from the scene and the surgeon stands on the same level, if not higher, in every respect with the physician in the eyes of the masses and the estimation of the scientific world. Modern pathology and the new science of bacteriology have laid a permanent foundation for the steady and progressive advance of surgical thought and work. The inflammatory complications of wounds and the etiology of most of the chronic infective surgical diseases have been cleared up by bacteriologic investigations during the last twenty-five years, and the knowledge thus gained has enabled the surgeon to prevent in a large measure the former and to treat intelligently and with increased success the latter. Many of the most noted surgeons who have left a strong and permanent impression on surgical literature and practice during the last quarter of a century have been enthusiastic and practical bacteriologists and competent pathologists. The wonderful development of operative surgery during the same time is one of the earliest and richest fruits reaped from the vast and fertile field sown and cultivated by bacteriologists of every civilized nation. To the immortal Lister belongs the honor of having opened a systematic and successful crusade against the surgeon's most treacherous enemies-the pathogenic microbes. The great principles which he conceived and introduced into practice created a new era in surgery. Antiseptic surgery is one of the many fruits of his genius and the one to whom we, as a profession, and humanity owe more than to any other surgeon dead or living, has been permitted to live long enough to see the creation and blessings of aseptic surgery, the handiwork of his innumerable enthusiastic followers. Antiseptic and aseptic surgery have smoothed the rough and rugged pathway of the practical surgeon. Ordinary cleanliness has given way to surgical cleanliness. The almost universal introduction of antiseptic and aseptic precautions in the treatment of wounds in private and hospital practice has nearly eradicated the three greatest enemies of the surgeon of old, namely, hospital gangrene, erysipelas and secondary hemorrhage, and minimized the occurrence of suppuration and its manifold immediate and remote complications.
No wonder that a sense of security created by such wonderful changes made the surgeon bold. In consequence of such revolutionary
changes wrought in the practice of surgery new territories were invaded and organ after organ, the seat of injury or disease, were subjected to direct surgical intervention. Step by step the scalpel found its way into localities where formerly the physician had reigned alone and supreme, and where its presence would have been regarded by him as convincing proof of homicidal intent. No better evidence can be advanced to show the difference in the kind and scope of work of the surgeon of to-day with the one before the pre-antiseptic time than a comparison between the works of operative surgery of now and then. The sense of safety which took possession of the surgeon and an earnest desire to extend his skill to the successful treatment of affections which had heretofore baffled the efforts of the physician, brought on a warfare on almost every organ the seat of real or imaginary disease. The physician found himself suddenly out of his long time honored routine practice. The specialist utilized the opportunity and left no stone unturned to extend their sphere of activity. Brain surgeons, abdominal surgeons, neck surgeons appeared on the scene and filled the medical press with accounts of their wonderful surgical feats. The old-fashioned gynecologist, whose chief occupation consisted in introducing and removing pessaries, cauterizing so-called ulcers of the cervix, swabbing out the uterus and inserting medicated vaginal tampons, became restless and anxious to exchange harmless, bloodless measures for the knife and scissors. His desire for bloody operations was not satisfied by sewing lacerations of the cervix and perineum. He felt that in order to keep abreast with the spirit of the present age he must increase his range of action, and in due course of time the ovaries, the Fallopian tubes and uterus became the theater of his aggressiveness. Even the acquisition of this additional territory did not satisfy his ambition. The adjoining great abdominal cavity, with its many important organs, was looked upon with a jealous eye and it has been made the common camping ground of the general surgeon and the gynecologist for several years.
The throat and nose specialist, under the same influences, became disgusted with his brush, powder-blower and atomizers; sharp spoons, chisels, and saws came into requisition, and the number of deflected septa, hypertrophic turbinated bones and third tonsil increased alarmingly and were attacked most energetically. The rectal specialist, who made a modest living by stretching the sphincter ani and ligating piles, saw a fortune in adding to his limited sphere of activity, resection of the rectum, and later, emboldened by his efforts, carried his crusade to the topmost limits of the large intestine. The average orthopedist
is no longer satisfied to correct deformities by the use of bloodless manual and mechanical measures; he has acquired a fondness for the knife, saw and chisel, so as not to be left behind in the procession. The genito-urinary surgeon has become tired of treating gonorrhea, strictures and syphilis; he can see no reason why he should not cut for stone, extirpate kidneys and perform plastic operations on the
The furor operativus manifested in these and other special departments of surgery, and its obvious results, render the standing and legitimate scope of the general surgeon very uncertain and indefinite at the present time. Let the general surgeon turn to the right or to the left, advance or retreat, and he finds himself on reserved territory. As for the physician, he is expected to answer night calls, prescribe for diarrhoea and whooping cough, watch cases of typhoid fever, measles, scarlatina and smallpox, and should complications arise and he does not report to the proper authority he renders himself liable to censure. Much of this ill-applied energy in the surgical world has resulted in detriment to patients and in retarding actual surgical progress. Operative surgery has been carried to extremes. A calm inspection of the ground that has been gone over will show "Some of the Limits of the Art of Surgery," the subject which I have chosen for this address.
Antisepsis and Asepsis.-The marvelous reduction in the mortality following injuries and operations which the present generation has witnessed is largely due to the prevention of wound complications by the employment of efficient antiseptic and aseptic precautions. Improved means of hemoitasis and the more efficient treatment of shock might reasonably claim a certain share in bringing about such a desirable change in the results of surgical practice, but what has made our work more satisfactory and the statistics of various operative procedures more encouraging is the prevention of infection, the protection of the patient against the immediate and remote effects of sepsis and suppuration. The treatment of wounds with these objects in view has been simplified and rendered more efficient from year to year, but it cannot be said that perfection has been reached. We are not yet in possession of an ideal absorbable ligature and suture material The person who will show us how to prepare the animal ligature and suture in such a way that it will not only be absolutely aseptic, but also antiseptic and without loss of its tensile strength, will be entitled to the lasting gratitude of the entire profession. The disinfection of hands and field of labor is open to future improvement. The important matter of drainage remains in anything but a satisfactory condition, and the questions
frequently raised, when to drain and how to drain, must be definitely settled by future experience and research. There are surgeons to-day who do not take into account the possible failure of antiseptic and aseptic precautions in estimating the dangers incident to operative procedures. Have we not all heard so-called abdominal surgeons say that an exploratory laparotomy is devoid of danger: Is it not a fact that the abdomen is being opened daily by men who have not the faintest idea of what they may have to do, simply because they regard such a step as harmless and free of danger and the shortest and easiest way to make a diagnosis? To say that such a blind confidence in the efficiency and safety of aseptic precautions is not in accord with the work of the conscientious surgeons is to put it mildly. It is fortunate for the patients of such ever-ready and self-confident operators that the peritoneum under ordinary circumstances can dispose of more pathogenic microbes without harm resulting than any other tissue of the body. If it were not such a serious matter it would be amusing to see how such men explain an occasional death that occurs in their practice in cases where it was least expected. If, perchance, a post-mortem examination was held, the first statement made is that the peritoneum showed no evidence of inflammation, consequently death must have oecurred in consequence of shock, exhaustion, bronchitis, edema of the lungs. or heart failure. Very recently a prominent surgeon in giving his testimonial in recommending a certain kind of cat-gut, made the statement that he had performed one hundred consecutive major operations without having seen a single drop of pus. I have no reason to doubt the veracity of this gentleman's statement, but I am firmly convinced that it would be difficult, if not impossible, to duplicate such an experience in the practice of the average general surgeon.
I have made it a duty on my part to familiarize myself with the advances made in the technique of aseptic surgery and have the good fortune to perform all my operations in two of the best hospitals in Chicago, and in a fairly equipped college clinic, and yet I amı only too willing to confess that I never finish my day's work without seeing pus. I have a painful recollection of two amputations for carcinoma of the breast on private patients. in both of which every possible precaution was carried out, and yet to my utmost disappointment, both of them died of the most virulent form of sepsis I ever encountered. To offset these cases, I might refer to perhaps over two hundred similar operations in which, under much less rigid precautions, with few exceptions, faultless wound healing was obtained. I remember, too, a case of genu val
gum in an adult treated by transcondyloid osteotomy under strict antiseptic precautions, where the operation was followed by violent suppurative osteomyelitis and extensive necrosis which for a long time seriously threatened the limb and life of the patient. I am sure that I am not alone in relating such experiences. Every surgeon is occasionally humiliated by such mishaps and here is the proper place to make open confessions. The careless, reckless remark so often made by men who ought to know better, that the surgeon who understands his business can make and treat wounds, which, if dressed properly, .will heal without suppuration, has reached the ears of the legal profession and has already entangled many a worthy and honest member of our profession in the complicated and trying machinery of the law. I envy the surgeon who has implicit confidence in this or that method of preventing wound infection, but I am confident that I but voice the sentiment of the vast majority of surgeons by making the statement that one of the limits of the art of surgery at the present time is the inadequacy of Our available resources in furnishing wounds, even under the most favorable circumstances, absolute protection against infection.
Phlegmonous Inflammation.--The ployment of antiseptic and aseptic precautions in the treatment of intentional and accidental wounds has greatly diminished the frequency of progressive phlegmonous inflammation and its often disastrous consequences. That such an occurrence cannot always be prevented, even by the most scrupulous care and attention to details, every surgeon of experience is willing to admit. In the most virulent forms of phlegmonous inflammation the most heroic and timely treatment, local and general, is often fruitless in averting speedy death. In the most desperate cases, the surface lesion is often insignificant, the infection following the lymphatic pathways, soon reaches the general circulation, resulting in death from acute sepsis before any decided gross pathologic lesions have appeared at the seat of infection or in any of the internal organs. How rapidly general infection may take place has been shown by the experiments of Schimmelbusch, who found microörganisms in the spleen five to ten minutes after infection of the wound. Colin and Niessen. demonstrated by their experimental work that amputation a few minutes after inoculation, of the ears and limbs of rabbits with pure culture of anthrax, did not protect the animals against generalization of the disease. Such cases in the human being fortunately are seldom met with, but when they do occur, the art of surgery is powerless in arresting the progress of the disease. Paren
chymatous injections of solutions of carbolic acid or corrosive sublimate along the course of solutions lymphatics, and the internal use. of alcohol in heroic doses promise the most, but in the great majority of cases the extension of the infection continues and terminates speedily in death from general sepsis. Whether bacteriology will furnish us with a more potent weapon in the treatment of such cases the future must determine. When the infection has resulted in suppuration the old adage ubi pus, ibi incisio remains as true today as before the microbic origin of pus was known. In the treatment of diffuse phlegmonous processes it is now customary to make free incisions, establish free drainage and disinfect the cavity by flushing it freely with a safe and yet efficient antiseptic solution, such as the saturated solution of acetate of aluminum, a 3 per cent solution of carbolic acid or a 1-5,000 solution of corrosive sublimate and apply to the part hot compresses wrung out of the same solution. A few years ago Helferich advised laying open of the entire cavity by a single incision, recently Kocher pleads in favor of small incisions for the reason that pus microbes multiply more rapidly when freely supplied with oxygen. I believe the best treatment is half way between these two extremes, that is, multiple incisions large enough to insert drains the size of the ittle finged with a view of establishing a perfect system of drainage. We cannot expect much from a single disinfection. In severe cases in which life is threatened by sepsis, I invariably resort to continuous irrigation with a saturated solution of acetate of aluminum, a non-toxic and yet very efficient antiseptic agent. The inflamed part should be immobilized and maintained in an elevated position until the inflammatory edema has subsided. The The same treatment yields the most happy results in the treatment of acute suppurative inflammation of the large joints. One of the great shortcomings of the art of surgery to-day is the lack of measures to deal more efficiently with progressive suppurative affections and secure for suppurative cavities an aseptic condition in a shorter and more direct way. In cases of circumscribed abscesses it is generally believed that the sooner the incision is made the more prompt will be the relief and the more speedy the cure. Clinical experience has not confirmed these expectations. The old surgeons applied emollient poultices until the abscess became soft before they used the bistoury. No modern surgeon has any use for the filthy germ-breeding poultice, for which he has substituted the antiseptic, moist, hot compress which answers the same purpose, as it furnishes the necessary heat and moisture, and at the same time prepares the surface for the incision. We are,
however, almost as powerless as our forefathers in limiting, much less aborting, a suppurative inflammation. One of the greatest and most useful innovations in surgery would be a remedy, local or general, which would. enable us to abort the process of destruction after the classical symptoms which characterize suppurative inflammation have set in. We must look to bacteriology to fill up this most important gap.
Acute Suppurative Osteomyelitis. Closely allied to phlegmonous inflammation of the soft tissues is acute suppurative osteomyelitis as it is caused by the same kind of microbes and results in more or less extensive destruction of tissue. The etiology and pathology of this disease are now well understood and upon them is based the early operative treatment which is generally endorsed by the profession at the present time. The danger from general sepsis is greater in the more serious forms of osteomyelitis than a similar affection of the soft tissues owing to the location of the primary focus of infection and the frequency with which the adjacent large joints beome implicated during the progress of the disease. The early removal of the osteomyelitic product by operative interference, as a rule, relieves pain promptly, limits necrosis, guards against joint complications and minimizes the danger from general sepsis. Immobilization of the affected limb in proper position and the exposure of the osteomyelitic focus by the use of the chisel or gouge as soon as positive diagnosis can be made are the modern resources which have succeeded in greatly reducing the mortality of this discase as well as its immediate complications and remote consequences. There are, however, cases of acute osteomyelitis in which the earliest intervention of the art of surgery is powerless in preventing death from general sepsis. These are the cases of osteomyelitis in which simultaneously or in rapid succession a number of the long bones become involved and where the local signs and symptoms are overshadowed by the general symptoms which point to a progressive sepsis and which are seldom favorably influenced by either local or general treatment.
Tuberculosis of Joints.-Only a few years ago the surgeons who paid especial attention. to diseases of the joints were enthusiastic advocates of early resection or arthrectomy in cases of tubercular joint affections. Typical resections were made regardless of the anatomical location or the extent of the disease. It was believed that such medical treatment would succeed in eliminating the local affection and in preventing the extension of the infection to distant organs by reinfection from the peripheral focus. Statistics prove that these hopes are unfounded and conscien
tious and thinking surgeons have substituted largely in place of operative treatment conservative measures. The surgeon forgets too often that tuberculosis of joints seldom appears as a primary affection, but, as a rule, appears as a peripheral manifestation of the existence of an antecedent perhaps undiscoverable tubercular affection of another organ, hence the removal of the accessible tubercular product does not necessarily protect the patient against tuberculosis of other joints, or organs, or general miliary tuberculosis. It is, on the other hand, a familiar clinical fact that the operative treatment of joint tuberculosis has not infrequently been followed by tuberculosis of other organs or general mil iary tuberculosis. The short-comings of the art of surgery are well brought forward in the treatment of tubercular joints. In large clinics where but a few years ago resection of joints for tuberculosis was a daily occurrence such operations are now rarely witnessed. This change in practice is largely due to the beneficial effects obtained from intra-articular and parenchymatous injections of iodoform glycerine injections. I have resorted to this treatment in hundreds of cases with the most satisfactory results. In about one-half or two-thirds of all cases of uncomplicated joint tuberculosis, this treatment proves curative. It is of special value in the treatment of tubercular abscesses in communication with a tubercular joint or bone, From one to three or four injections usually suffice in obliterating the abscess cavity. The tapping and injection must be done under the strictest antiseptic precautions lest the operation will aggravate the case, perhaps render it hopeless, by becoming the direct cause of a mixed infection with pus microbes. As some persons are peculiarly susceptible to the toxic action of iodoform the minimum dose, two drams of a 10 per cent. emulsion, should be used in the beginning. In cases complicated by renal affections this caution should be increased, as any affection of the kidneys retards the elimination of the iodoform and thus increases the danger from intoxication. Another important precaution in tapping a tubercular abscess is not to puncture the skin where it is thin and cyanotic, as when it is made in such a place the puncture is very liable to give rise to a fistulous opening and consequently increased risk of infection with pyogenic microbes. The puncture must be made through normal skin, if need be some distance from the abscess, and after removal of the canula, it should be sealed with iodoform collodium and a small pledget of sterile cotton. Immobilization of the limb or part thus treated is often useful but not always necessary. During the process of repair initiated by the iodoform injections, the capsule