The Evolution of Surgery
The Evolution of Surgery
WILLIAM THORBURN, F.R.C.S.,
Professor of Clinical Surgery.
An Address delivered on October 3rd, 1910, at the
Opening of the Medical Session, 1910—11.
AT THE UNIVERSITY PRESS
The Evolution of Surgery.
Mr. Vice-Chancellor, Ladies and Gentlemen,
Among the many causes which make me regret having to appear before you to-day there is none stronger than the fact that I do so because my old friend and teacher Mr. Southam has ceased his active connection with our medical school. My earliest recollection of the old Manchester Infirmary takes me back to the days when he was a resident there. My earliest recollections as a student centre round his teaching. My first operation was performed under his eye and as his dresser. And from then until to-day I have always found him the same kind friend, the patient teacher, with the clear sound judgment and the great faculty of recognising his true aim and discarding the unimportant, whether in surgery or in general conduct, and of then pursuing that aim steadily, unflinchingly, until finally he had achieved his goal. For thirty years his clearness of view and his strength of purpose have had a value for our medical school which we have perhaps hardly appreciated, because his own modesty has somewhat hidden his own worth, but those who know him best, best know that in him we have lost a teacher and a colleague whom we shall not readily replace.
But it is only as an active member of our staff that we have lost the services of Mr. Southam; fortunately he is still with us, and we look forward to many years of his presence and assistance. It is not so with one other who has passed away since we last met in this building. John Edward Platt was a student when I had begun to be a teacher. His was in many respects a character not unlike that of Southam. He had the same quiet efficiency. He had the same faculty of doing rather than of talking. We might fairly have hoped that twenty years hence he might have retired with a long record of useful service for our school and for surgery. But like so many others of our colleagues he has been cut off early in his career, and we can retain only the memory of what he was and the inspiration of what he would have been. Such a loss is irreparable and you will all feel with me to-day how much we are the poorer by this last gap in our ranks.
Nor can we meet to-day without recalling another loss: the loss of one who was not a member either of our profession or of our University but who had done more than many of ourselves to promote the welfare of this school. If, as I believe, the greatest aim of medical education is to provide the public with able practitioners, if the first essential for so doing is the perfection of our clinical teaching, and if, as our experience has shown, this demands a close and more than friendly co-operation between our University and the Medical Staff and Board of Management of our Hospital, then indeed we owe a debt of gratitude to the work of John Dewhurst Milne. His courtesy, his breadth of view, his perfect honesty, the intense loveableness of the man—these things have done more for us than can be readily appreciated by those who have not been closely associated with the working of our school. I am not alone in this room to-day in having lost in him one of the dearest and best of friends.
But to-day, Gentlemen, we are concerned not with our personal losses but with the gains of that art which so many of you will practise in the years to come, and I hope to trace with you something of the evolution of surgery as I have seen it since the time when I had the privilege to be one of Mr. Southam's students. In those days we used as our guide in all surgical matters a text book which was not only by far the best of its day but which still in many respects presents a model of what a text book should be. All of us—even the least industrious—read the first two pages of this work, and there we found the following statement as to the point of evolution which surgery had then reached.
"Operative Surgery," says Erichsen, "like every other art, can only be carried to a certain definite point of excellence. There cannot always be fresh fields for conquest by the knife. There must be portions of the human frame that will ever remain sacred from its intrusion. That we have nearly, if not quite, reached these final limits there can be little question. To my mind it appears as if we had already reached something like finality in the mere manipulative art of surgery and in this direction the progress of modern surgery is nearly barred."
These words were written, or at least published, in 1884: the work of Lister was already known and his methods practised throughout the world: the new surgery had begun but few if any foresaw its rapid evolution. The very word "aseptic" was then not used of operative measures. Local anaesthesia was as far removed from our thoughts as was chloroform from those of Hippocrates. And when we seek for information upon the diseases of those organs whose surgical treatment now constitutes most of the work of our hospital we find an absolute and complete blank. Let us take but two examples—the familiar and almost friendly adenoids of our childhood and the appendicitis which brings so much of interest to all our lives and so much of profit to the surgeon: neither of these diseases is mentioned or was then known, while, so far as the latter is concerned, probably any attempt at surgical treatment would have been very promptly fatal. Were it profitable it would be easy by continued quotation from the text books of that day to show you that the changes which some of us, who are yet far short of the allotted span of human life, have seen with our own eyes and practised with our own hands, have implied an evolution in surgery not less wonderful than the development of rapid locomotion, of distant communication, or even of aerial navigation. But it will perhaps be of more interest if I try to indicate to you from a comparatively short personal experience what this growth has been, and although I do not wish to trouble you unduly with statistics I would first invite your attention to a few figures which may bring home to you what the human race has gained in one quarter of a century.
In the year 1883 I became a house surgeon at the old Manchester Royal Infirmary, and in 1908 we saw that building closed for ever. With some personal bias in favour of such land-marks I have tried therefore by comparing the registers of these two dates—exactly a quarter of a century apart—to learn what the gain has been in our hospital alone—the gain in saving of life, in saving of limb, in saving of suffering, and in the mere economic saving of disablement from ill-health which bears so heavily upon our bread winners.
Let us first look at the mere volume of surgical work in the two years which we are to compare. In 1883 the Manchester Infirmary had one operating theatre which was used about three times weekly, and the annual number of operations of all kinds was about 600. In 1908, in the same old building about four times as many operations were performed, and their importance was far greater, as many of the slighter ones were no longer entered in our registers. Or again in the first period about one-fourth of all surgical in-patients were operated upon, while in the second the number was nearly threefourths. In spite however of this great increase in the amount of work the percentage of deaths after operation had fallen from about 10½ to about 8½, these numbers including deaths from all causes whatever and not by any means only those due to operation, which, could we define them, would be far fewer. Thus in 1883 we find that nearly one-fifth of the deaths after operation were due to infective conditions which are now so far preventable that we cannot possibly attribute more than one per cent, of the present mortality to such causes.
It is, however, when we turn to special classes of disease that we find still more striking evidence of change. In 1883 the abdomen was opened with fear and trembling, and abdominal operations were performed only in the hope of averting directly threatened death, while they were rarely if ever resorted to in order to relieve suffering, to restore true health, or to prevent future catastrophes. Thus in the year of my house surgeoncy we find but 12 operations on the abdomen of which seven, or more than half, died, while in 1908 we find nearly 500 of such operations with a mortality of about 11 per cent., the mortality including deaths from such conditions as hopeless cancers, injuries and the like, and the large number due to too long delay in securing treatment. When you reflect that in one hospital alone this means an average of between one and two persons relieved daily from diseases of the abdomen, which would otherwise have been almost certainly either fatal or a cause of lifelong disablement, you will appreciate what such figures mean.
I will not weary you by tracing similarly the surgery of all regions, but I may tell you briefly a few other facts of this class. Many of the diseases of the kidney are very fatal or very painful, or both. In 1883, three such cases were operated upon: in 1908 we operated upon 92. The liver and its ducts are not mentioned in the registers of 1883: in 1908 there were 52 operations for such painful and dangerous conditions as gall stones and other affections of these organs. The thyroid gland, whose swellings constitute so great a source of disfigurement, of general ill-health, and of fatal pressure, was equally neglected in the early period, while 27 cases were operated upon in 1908.
True you may say the fact that we operate does not prove that we cure, but I could show you, were it not that I should weary you with details, how, in every case the safety of the operations themselves has also increased. As an illustration we will take a single instance. In 1883 there were removed 29 cancers of the breast, and of the patients 3, or say ten per cent., died: in 1908 we removed 62, by a far more radical method giving far better ultimate results, and we had no deaths at all.
I hope I have succeeded then in showing you by these figures—figures eloquent in themselves however ineloquently presented—the gain in the saving of life and in the removal of causes of life-long suffering.
Let us next see what has been done as regards the saving of limbs. In a great manufacturing centre like ours there are constantly occurring severe accidents, some of which will always necessitate the amputation of damaged limbs, while amputation has also to be resorted to as the only hope of saving life in some incurable diseases. So common were such cases in the recent past that many people still regard a surgeon as a man "who cuts off legs." But yearly he is becoming more and more a man who prevents the necessity for cutting off legs. In 1883 one-sixth of all the operations performed were amputations, and of these again one-sixth died. In 1908 only one operation in fifty was an amputation, and the death-rate had fallen to one in twenty-five, so that not only were many limbs saved, but the mortality was reduced in a similar ratio.
Closely analogous to amputation from our present point of view is the operation known as the "radical cure of hernia," which by curing ruptures increases greatly the efficiency of the man or woman who has any form of work to do, relieves him or her from the disagreeable necessity of wearing a truss, and removes a definite risk to life. In 1883 this operation was performed three times, and the results were very uncertain: in 1908 it was performed 264 times and nearly all cases are permanently cured.
And, lastly,—in order that once and for all I may have done with statistics,—let me show you how far time has been saved to the disabled worker when I tell you that in the earlier of our two selected years the average hospital treatment of a surgical in-patient was twenty-one days, where now it is but nineteen days: not a great difference you may think in the case of each individual, but a very definite gain to the whole community.
You will be as pleased as myself that I cannot show you by means of figures what has been saved in pain and suffering. Those only who remember the time when every wound required an almost daily dressing with the recurrent handling of more or less inflamed and intensely painful surfaces, can realise what it means that we now leave our operations untouched for a week and then uncover the wounds we have made to find with almost absolute certainty a perfectly healed surface. The operation of to-day implies as a rule a few hours of slight smarting, and about two days of discomfort from the effects of the anaesthetic and the early stages of confinement to bed, after which the tedium of convalescence is almost the sole remaining trouble.
Thus it is then that almost imperceptibly and year by year we of this generation have seen the outcome of Lord Lister's great work, and have seen results from it of which he himself could have had no conception. For surgical advance unquestionably owes itself to two great fundamental discoveries—anæsthesia and asepsis. Of anaesthesia I shall say nothing: I am thankful indeed that it came long before my day. Whether the future may hold for us a perfection in the methods of local or spinal anaesthesia which will entirely replace general narcosis or not, at least we have now means of relieving immediate pain and shock so perfect, and on the whole so safe, that we can always operate slowly, carefully and with precision. The hurried and "brilliant" surgery of former days is past for ever, and never again need we sacrifice accuracy to the fact that human agony could only be endured for a very limited period.
But as regards asepsis, the full value of Lister's work had not been realised in 1883 and the evolution of surgery in the five and twenty years of my personal experience has been mainly the development of this great advance—a development the lines of which I hope to be able to trace to-day.
It is, of course, notorious that life and limb are saved by preventing the diseases of wounds, and by the practical abolition of pyæmia, septicæmia, erysipelas, spreading gangrene and suppuration. But it would seem to me that the operative technique of surgery owes much of its progress to a less well recognised result of completely aseptic wound treatment. Apart from the graver infections almost every wound was formerly associated with at least some surrounding inflammation. Even in the slightest of cases there was an area of redness extending for about half an inch from the cut surface. This area presented some swelling, it was painful and tender and the tissues involved had lost something of their normal vitality, so that if at all freely detached from their blood supply they were liable to slough or die. It matters not for our present purpose how far this was due to imperfect sepsis or how far it resulted from the irritant action of chemicals used to prevent the more severe infections: the fact remains that five and twenty years ago most wounds did present some such change and that therefore we could not be certain when we operated that the injury inflicted would be absolutely located to the tissues mechanically divided. To-day this is no longer the case. To-day we know that the injury done by the knife is limited to the track of the knife itself and that it will be repaired with a rapidity so great that after a very few hours the most extensive dissections have left no obvious trace.
It is probably to this fact above all others that we owe the can now be laid bare as in the dissecting room: great joints can be opened up and closed again with almost every fibre in its original position: the abdomen is opened without cutting its muscular walls: the brain is exposed, not through a hole of say an inch in diameter, but by turning down the side of the skull like the lid of a box and replacing it at the end of our operation; even the heart itself has of late been similarly dealt with. The perfection of asepsis has so wholly altered our methods that the greatest advances in the mechanical art of surgery in my day have I think been due to a freedom of action and an exposure of the field of operation which were formerly incredible.recent extension of surgical dissection. The surgeon of to-day must avoid the cutting or bruising of structures essential to life. There are tracts in the brain and in the spinal cord which he must not divide: there are a few—a very few—great blood-vessels which he must not tie or cut. But with these reservations he finds no barrier to his work. He can safely open, divide and restore the great canals and ducts of the body. He can freely expose all its cavities and work in their interior with calm and confidence. He is not limited to a short direct incision giving an imperfect view of what lies beneath; he can fully reveal the parts he has to attack. Imagine to yourselves the study of a picture covered by a sheet, if, on the one hand you must be satisfied to look through a hole in the covering, or on the other hand you can raise or draw aside that covering, exposing the entire picture to view, and then replacing it with accuracy and without injury. It is by raising the covering sheet that we now commence most operations of importance. The tissues of the body
Following this accuracy of dissection we take a further step which has also greatly assisted the evolution of our art. We now obtain a complete view of the effects of disease and of diseased areas which our predecessors did not possess and dared not seek, and in this way modern surgical operations have taught us much of the real nature of disease. So long as treatment is confined to the use of drugs or to a few comparatively simple operations with a minimum of anatomical dissection we rarely become thoroughly acquainted with pathological processes: the affected parts are never seen during life and we have either no visual knowledge of them at all or such knowledge as we do possess is derived from an examination made after death, when the ultimate stage alone is seen, and seen under conditions far different from those of life. But let surgery enter the field and we acquire at once an actual concrete picture, certainty replaces conjecture and we act with confidence instead of groping in the dark. How many centuries of "clinical observation" went by without the recognition of appendicitis, of the results of pyloric obstruction, or of the diseased conditions of the gall bladder. But now that the surgeon has fully explored the once dreaded abdomen all these things have become common-places of our knowledge.
We smile to-day at Aristotle's view that the brain was an organ destined to cool the heart and that the latter was the organ of the mind, and we find it hard to believe that there could be rational therapeutics before Harvey discovered the circulation of the blood, but surely our knowledge of many diseases with which surgery now deals daily is almost as much a revelation to the present generation as were the fundamental facts of physiology to a former day. The acquisition of this knowledge of diseased processes during life and during their early stages, and the precision of observation obtained in recent years have I think altered our whole mental attitude and given us a clear conception of the objects of surgery which marks a further stage in its evolution. What the skiagram has taught us about the bones the human eye has taught us about the rest of the body, and we no longer think and speak of pathological conditions as our fathers imagined them to be but as we ourselves have seen them.
And again we are led by a most natural transition to another factor in the evolution of surgery. The extension of operative treatment has demanded and obtained an accuracy of diagnosis which was formerly not required and not obtained. The operating surgeon has been obliged to make a call upon the physician which the latter has had to meet. Perhaps I may say, without offence to my medical colleagues, that in the great majority of diseases not capable of surgical treatment exact diagnosis has little but an academic interest. Five and twenty years ago if a man had a tumour of the brain or spinal cord it was of no practical importance where it lay or what it was. But the moment that surgery can undertake to remove some of these tumours and thus to cure the patient it becomes absolutely essential to know their exact size and position and as far as possible even their shape and consistency. This knowledge is urgently required in order that we may answer the questions, can it be removed, and where is it to be looked for? Or again let us consider the acute diseases of the abdomen. A quarter of a century ago all or nearly all of these were fatal: death was assigned to peritonitis: certain drugs were used to relieve symptoms but nothing radical could be done, so peritonitis held the field and was a general expression for many conditions which were not distinguished because their distinction was of no practical importance. But now we know that to use the term peritonitis as describing the disease is about as enlightening as to speak of failure of the heart or cessation of respiration, and we recognise that it is but the late result of many diseases, most of which are curable by operation if the latter be performed promptly and the true starting point of trouble be attacked. Hence surgery has called for the early diagnosis of all the causes of peritonitis and to-day the diagnosis can be made and is made. The extension of our mechanical technique has not only taught us pathology; it has made us learn diagnostic medicine.
Thus then the lines of advance after the elimination of pain and wound infection have been mainly the free exposure of diseased parts, the fuller knowledge gained thereby, and the more prompt and accurate recognition of the early stages of disease. Each factor has reacted upon the other. Each step has called for the next and has made the next more easy; as quickly as the trail is made it is trodden by many feet and in a very few years the jungle has become a network of solid roads from which again new byways are ever opening out.
Lastly, much has been gained in these past years by the education of the public. Some time ago I tried to show how the mortality from strangulated hernia had been diminished in a short twelve years, not only by improvements in the method of operating but also by an increased appreciation by the profession and the public of the necessity for promptitude. Not many years ago the patient "submitted to operation," as it was called, only after long delay, after many conferences with friends and with those surgeons who were almost regarded as foes, and after a prolonged trial of methods differing little from those of the days of Galen. To-day there is little question of "submitting to operation"; it is now often more difficult for the surgeon to discourage the useless than to urge the necessary. The laity has learnt what can be done and the consequent demand for the surgeon's service has tended ever to increase the value and the readiness of that service.
And thus we now attack nearly all the strongholds of disease while new triumphs and new conquests follow with bewildering rapidity. In 1876 Lawson Tait first removed some stones from the gall bladder and the daring operation was regarded as one which might be occasionally adopted: in 1909 Mayo Robson had collected 3,000 of such operations performed by three surgeons alone, and with a mortality of less than 2 per cent. Some 20 years ago the operation of gastroenterostomy was introduced to surgery: it is now one of the commonest of remedial measures and many thousands have been rescued by it from the slow martyrdom of so-called dyspepsia. In 1896, an Italian surgeon. Farina, made the first attempt to suture a wound of the heart itself and in 1909 Vaughan collects 150 cases with 35 per cent, saved from certain death. Still more recently we have seen successful operations for the diseases of the heart, while an ingenious device now makes it possible to open the chest with the surrounding atmospheric pressure reduced to that in the bronchial tubes and thus to operate upon the lungs and pleura. Not long ago the diseases of the brain and spinal cord were beyond the reach of surgery but they are now attacked with no inconsiderable measure of success, although we must admit that in this branch of our work we have had many disappointments, mainly, perhaps, because diagnosis has here not kept pace with surgical requirements. And of the other great organs of the body we have said enough. Surely operative surgery had not reached finality thirty years ago, and surely we may look to the future for an evolution not less wonderful than that of the past.
But, gentlemen, there are few gains which carry no losses in their train. When we speak of our triumphs and our hopes let us not forget our perils and our pitfalls, and let us pause for one moment to ask ourselves what may be the greatest dangers of modern surgery.
In the first place we have perhaps a tendency to operate too readily, and without due care for preliminary diagnosis. Doubtless it is better to "look and see" than to "wait and see," but it is better still to look with the clearest possible certainty of what we look for. Haphazard explorations and operations undertaken because "something must be done" are a moral crime from which we are perhaps not altogether exempt. The very safety of surgery tends to diminish the sense of responsibility with which such operations are undertaken. The fact that in so many cases an operation is performed with ultimate recovery may also make us lose sight of the fact that recovery might have occurred without the operation, and that the latter is not in itself a good or a desirable thing even in the 20th century. At the outset of your career, gentlemen, I would beg of you always to ask yourselves before operating, "Is this necessary?" and to remember that unless you can answer in the affirmative even the modern operation is a thing to avoid, while it should never be undertaken without a clear and definite aim.
A closely allied danger is that of extreme specialism which is another term for limitation of thought. Our bodies are not made, like our ships, in water-tight compartments. You cannot derange one organ or one function without also injuring others. Specialisation is to some extent inevitable because the ground to be covered in the study of medicine is so enormous that no human being can be equally familiar with all its parts, and in surgery especially the acquirement of technical skill requires the concentration of our attention on certain regions. But although inevitable it is none the less a misfortune of modern surgery. It tends to narrow our view, to make us lose sight of the human being in the consideration of our own favourite corner of his frame, to lead us into locating all his ills in that corner, and sometimes perhaps to make us operate upon that corner when it would have been wiser to adopt other measures. Is there not reason to fear that there are to-day some well-known, greatly distinguished and exceedingly brilliant surgeons whose reputation for, let us say, amputating the little finger, is somewhat shadowed by the suspicion that they may amputate that digit when it was hardly worthy of such honour? This tendency we all have to resist and resistance is not made more easy by the attitude of the laity who almost demand that our work shall be thus one-sided, although they are not always so crude in their reasoning as the gentleman who, having been told that he was suffering from neurasthenia, looked up that condition in an Encyclopaedia and then consulted a well-known surgical "specialist" on the ground that he found it in the appendix.
On the other hand it is also doubtful whether our present lines of professional cleavage are the best. To-day we make a sharp division between medicine and surgery, a division dating from long before the dawn of modern surgery. We have physicians who devote themselves to one branch of therapeutics and surgeons who perhaps tend to exaggerate the other. Is this a good thing or is it a permanent condition? This question I for one am not prepared to answer. We may admit that in many cases the patient would probably be the gainer if the physician were ready and able to perform his own operations—if, for example, the great neurologist could remove the cerebral tumour. On the other hand we must admit that a wide experience of general surgery is essential to one who would perform any operation and that, if the physician is to operate at all, the members of the senior branch of our profession must condescend to soil their hands with all the details of the work which we surgeons have evolved from the homely task of the mediæval barber. That this could be done and might be done is possible, and I think it not improbable that ultimately it will be done. At least there is a great precedent in its favour in the fact that a large section of the surgical work of twenty-five years ago has now been cut adrift under the name of gynæcology, in which branch of medicine the old distinction of physician and surgeon has almost disappeared.
However this may be, let us not lose sight of the fact that after all the greatest surgeon is the greatest healer, and not necessarily or invariably the most dextrous operator. And we may humble a little our pride in our art when we consider that it must always remain but an imperfect means towards one great end—the extinction of disease. Great as have been its triumphs and greater still as we hope to make them, the greatest triumph will be when a fuller knowledge of the causes of disease, a more perfect development of preventive medicine, a higher evolution of social law, and a nobler gift of individual self-control shall finally eliminate or shall truly cure those human ills with which, in our imperfect knowledge, we still deal so crudely. The removal, the readjustment and even the replacement of parts of the human frame are not in themselves our ultimate ambition. At the best we may venture to hope that they are but a passing phase, for, however skilfully we may handle the knife, it must always be an evil in itself and the day may come when it can be laid aside forever. Surely we may trust that in the endless war against disease, the scalpel and the suture are no more the final hope of medicine than are the Dreadnought and the rifle the last resource in the civilisation and progress of mankind. Doubtless, gentlemen, it is too much to hope for the realisation of such a dream in the lifetime of any who are here to-day, but it is not too much to expect and trust that you who are now devoting yourselves to the great study of medicine may hereafter play a worthy part, not only in advancing the art of surgery, but also in replacing that art by the still more perfect methods which it is our duty to seek and to which ultimately we may attain.