MOiO
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OF CALIFORNIA
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h.ssays on |
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By BERKELEY MOYNIHAN K. C. M. G., C. B. Leeds, England |
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Illustrated |
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Philadelphia and London B. Saunders Company 1921 |
Copyright, 1921, by W. B. Saunders Company
PRINTED IN AMERICA
PRESS OF
W. B. SAUNDERS COMPANT
PHIIiADELPHIA
0Mne&a| Ukaxj
WO
To Dr. W. J. Mayo Dr. C. H. Mayo
AND
My friends at the Mayo Clinic
A small acknowledgment of a
great debt
624000
PREFACE
This book contains a number of essays that have been pubhshed at various times during the last few years. A few alterations have been made, and the sta- tistical figures have been brought up to the end of the year 1920.
The pubhcation, in a single volume, of addresses, lectures, and essays that have appeared in different journals, and at varying intervals of time, may find its justification in that it presents a consecutive train of thought and experience for , final judgment. And I may truthfully plead that the wishes of many friends have led me to collect these scattered articles in the present little book which I offer for their consideration.
My thanks are due to the Editors of the journals in which the articles originally appeared for their per- mission to republish them here.
Berkeley Moynihan.
33, Park Square, Leeds, Augusi, 1921
CONTENTS
PAGE
The Murphy Memorial Oration 1
The Ritual of a Surgical Operation 45
The Diagnosis and Treatment of Chronic Gastric Ulcer 67
Disappointments After Gastro-enterostomy Ill
Intestinal Stasis 131
Acute Emergencies of Abdominal Disease 143
The Gifts of Surgery to Medicine 167
The Surgery of the Chest in Relation to Retained Pro- jectiles 197
The Most Gentle Profession 247
Essays on Surgical Subjects
THE MURPHY MEMORIAL ORATION*
"The moral of the whole story is this: thai vx should do all thai we can to pcwlake of Virtue and Wisdom in this life." — Socrates is speaking.
This is a day of remembrance. We have come to- gether to do honour to one of the founders of this College, a great surgeon whose loss we mourn. You have laid upon me the duty and the high privilege of oflFering in your name and in my own, and if I may for the moment assume a wider responsibility, in the name of all the surgeons of his time, a tribute to the illustrious memory of Dr. J. B. Murphy.
John Benjamin Murphy was an arresting personality. Even after the briefest intercourse with him there were few people who did not reahze that he possessed a curious and subtle power of impressing a sense of his character upon them. His very handsome. face, his tall, spare, almost gaunt figure, his high-pitched and vibrant voice, his burning and quenchless enthusiasm for life in all its manifold activities, his power of complete self-expression, all clamoured for notice, and caught and held the most eager attention. His outlook was grave and serious; he seemed always in earnest. The little quips and sallies, the friendly taunts, the provocations to repartee, the illuminating anecdote, which in the United States dis-
* The first Murphy memorial oration delivered before the American (College of Surgeons, at Montreal, October 11, 1920. i i
ESSAYS ON SURGICAL SUBJECTS
tinguish the cordial intimacies of daily life, did not seem to play around him as freely as around other men. Even in a crowded room of busy men, or when a debate was keen he would steal a few moments for a whispered conversation, held aloof, on some topic that for the moment filled his thoughts. Among those who knew him well he was admired and deeply respected, rather than loved. Except to a very few he was not genial or respon- sive in friendship. His intellectual attainments were so considerable, and his position in the judgment of his contemporaries so secure, that jealousy hardly touched him, except perhaps in his earher years and from a few among his seniors whose supremacy he challenged. Such jealousy is perhaps the tribute paid to youth for successful enterprise in thought or in action by minds which suffer from the atheroma of advancing years. We are reminded of the aphorism of Sir Walter Raleigh
"For whoso reaps renown above the rest With heaps of hate shedl surely be opprest,"
Murphy was beyond question the greatest clinical teacher of his day. No one who Ustened to him can ever forget the experience. Before his audience arrived he had everything very carefully prepared, diagrams in order, microscopes ready, the patients examined, and all relevant literature at his finger ends. There he stood in the middle of the circle, in the theatre, with his assistants and friends in the first row and the other benches packed to the roof with eager students, or with medical men, who came again and again to learn from him afresh. As he began to speak one felt a strange sense of disappointment, and even of dismay. For while the handsome face and upright figure were things of real beauty, the voice in
THE MURPHY MEMORIAL ORATION
which he began to speak was quite unpleasant. It was harsh, even raucous, high pitched, shrill, apt to wander into other keys. It seemed strange that a man of Irish descent, and of so gracious and commanding a presence, should have a voice so lacking in softness, one which not only did not appeal, but actually displeased and almost repelled every hstener. But as he continued speaking the voice graduaUy ceased to distract, it became smoother, quieter, and more evenly pitched, and all thought of it was now lost in rapt attention to the matter. For things were happening even while one's first emotions were roused. Questions were being asked and answered, often with great rapidity, then would come a pause, in which with marvellous directness and power the lesson to be learnt therefrom was driven home. The rally began again. A poor answer came, or an assistant responsible for the cHnical notes had omitted to inquire upon some relevant point; raillery came in torrents, never ill- natured, never rancorous, but with just sufficient sting to leave a memory which would stimulate all future work. The discussion warmed imperceptibly; gradually the co- herent chain of argument lengthened, as fink after hnk, forged under our eyes, newly appeared; slowly there came a sense of excitement; of impending revelation; all inquiry, all disclosure, all arguments, were leading up to something that we now ached to learn. Old observations and ancient truths were taking on a new complexion; relations hitherto unsuspected were here declared and explained. The whole intellectual mechanism underlying a great subject was being shewn both in detail and in all the majesty of many moving parts. Perhaps as we drew near to the end, when the whole story would be laid bare, a question barked at one of his audience would fail
ESSAYS ON SURGICAL SUBJECTS
to be answered. With voice more clamorous, and almost menacing, with face strained and eager, with figure reaching forward and arm outstretched, he would hurl the question at others. Hearts beat faster, the spiritual anguish could hardly be borne. At last the answer would come, and after a final swift induction or brief summary, when the clinical journey was over, we sank back in happiness and mentgJ repletion to wonder if Stevenson could really have been right when he said, "It is a better thing to travel hopefully than to arrive," for this journey had been happy, though anxious enough, but the haven was a rest of tranquilhty, and wonder and content.
And then Murphy would operate. Now of operators there are many types, and Kke every other work of art, an operation is the expression of a man's temperment and character. There are still among us "brilHant" operators, from whom I pray to be spared when my hour has come. For them it is the mere quahty of effort that counts. Their ideed of operative surgery is something swift and infinitely dexterous, something to dazzle the beholder, and excite his wonder that such things can so be done by human hands. The body of a man is the plastic material in which an artist works, and no art is worthy of such a medium unless it has in it something of a sacrament. Surgery of the "briUiant" kind is a desecration. Such art finds its proper scope in tricks with cards, in juggling with billiard balls, and nimble encounters with bowls of vanishing gold fish. But Murphy was of the true faith. He beheved in safe and thorough work rather than in specious and hazardous briUiance. He was infinitely care- ful in preparation, and compared with many was incHned to be slow; but every step in every operation which I ever saw him do was completed deliberately, accurately, once
THE MURPHY MEMORIAL ORATION 5
for all. It led inevitably to the next step, without pause, without haste; that step completed, another followed. "In sequent toil all forwards did contend." And so when the end came a review of the operation shewed no false move, no part left incomplete, no chance of disaster; all was honest, safe, simple; it was modest rather than bril- hant. During the whole operation Murphy talked; not wasting time, but expressing and explaining aloud the quiet, gentle, dexterous movements of his hands and the purposeful working of his mind. The operation over, he would draw his stool near to the front row of the benches, cross one leg over another, rest his elbow on his knee and talk, as only he in all the world could talk, of surgery in general, of this case in particular, of his faults, of any experiment made to clear a doubtful issue. In these quiet talks there was none of the earher passion which had gleamed through him, and which, caught up by his audience, had made them throb and tremble with suspense or joy. In them all his former experience, all that he had learnt by contact with men and books, aU his native ingenuity of mind, were now bountifully dis- played : the vast resources of the keenest surgical intellect of his day were now disclosed, not with ostentation or with florid pride, but in such a quiet manner as to shew that he rejoiced in the privilege of sharing with others so many fascinating and wonderful things. If in answer to a request a httle intellectual gift were made to him, it was welcomed with frank, almost boyish enthusiasm, and with a dehght and humihty obviously genuine.
Murphy as a writer and as a speaker was prolific. Whenever he spoke men made haste to hear him. His audience, or so it always seemed to me, were often held back from quick appreciation. He was not like other
ESSAYS ON SURGICAL SUBJECTS
men instantly attractive as an orator. Yet, as he devel- oped his argument, little by Httle, and step by step, the audience warmed to him, he interested them, he in- trigued them, he dominated them, he fired them; intellec- tually he roused them to breathless interest; emotionally they were at times at the hmit of self-control. No one could bear to miss a word, and while Murphy spoke no man left his seat. For his meaning was conveyed in pellucid language and though he might speak with the vehemence of raging conviction his thought was never obscured in a smoke of words. Such an intellectual lode- stone was he that appointments were missed and hunger and thirst and fatigue were forgotten. For while Murphy expounded his gospel everything else seemed to fade in importance, overshadowed by the lessons which were now being learnt so eagerly.
I often wondered, as I hstened, in what degree he resembled Lincoln. The tall, gaunt frame, and the harsh and meagre and strident voice were the same. Murphy must have been one of the handsomest men of his day; Lincoln's features were haggard, plain and homely, but his deep and glowing, sad and tender eyes no man could forget. Murphy had no such command of language as Lincoln, certainly one of the greatest orators who has ever spoken our language. But in effect they must have been alike. For they made everything else seem common- place when they spoke, and they seemed to be deHvering a message charged with truth and pregnant with con- fidence and hope. Lord Charnwood in his most excellent work on "Abraham Lincoln" writes of him: "His voice when he first opened his mouth surprised and jarred upon the hearers with a harsh note of curiously high pitch. But it was the sort of oddity that arrests attention, and
THE MURPHY MEMORIAL ORATION 7
people's attention once caught was apt to be held by the man's transparent earnestness." How exactly was this the case with Murphy also I No one who heard Murphy speak ever doubted his sincerity. One might not agree; one might indeed profoundly and confidently disagree with some statement he made, perhaps as though to provoke a challenge, for there was much in Murphy which justified his patronymic, and which discovered his an- cestry; but there was never a thought that Murphy himself was speaking other than his deep and tried con- viction. He never looked at truth askance or strangely. One who heard Lincoln speak at Peoria wrote: "Beyond and above all skill was the overwhelming conviction imposed upon the audience that the speaker himself was charged with an irresistible and inspiring duty to his fellow men." Such an impression was often felt by audiences while Murphy was addressing them.
One thing Murphy lacked ; in one respect he grievously failed. If we consider the quahties which go to the mak- ing of the greatest surgeons, a foremost place must always be conceded to the capacity to train great disciples. The teaching, the diUgence, the general outlook upon surgery and a finished technical skill can all be drilled into the minds, and imposed upon the methods of an earnest student. But it is the inspiration, the lofty sense of a sacred mission worthy of all the best that is in you, the dedication with humblest and fullest devotion to the cause of scientific truth, and of loyal service to mankind, that are awakened with a thrill in great men by great teachers. It is here that Murphy fell short. He trained no one worthy to be his successor; no evangehst who could carry into other chnics or to other countries some of his glow, his fervour, his complete devotion, or the full meaning of
ESSAYS ON SURGICAL SUBJECTS
his gospel. For this great omission there were periiaps some compensations. There were few chnics in any part of the world in which something taught by Mm'phy or inspired by him had not crept in and found a home. His name was often on the hps of surgeons in all lands. His views impressed themselves on men's minds. His methods were closely copied. But when Murphy laid his mantle down there was no one ready and worthy to take it up. When we remember how the pupils of Turner, of Edin- burgh, became professors in most of the chairs of anatomy throughout the British Empire, how many men BiUroth trained to occupy with great distinction the chairs of surgery in eastern Europe, how Welch is the happy parent of a great school of pathologists trained by him, inspired by him, and looking to him with reverent affection, we cannot refrain from regret that some of the acolytes of Murphy did. not grow to the stature of High Priests.
Year by year Mm'phy grew in intellectual power and in the dominion he exercised over the minds of men. A problem took on a different aspect if Murphy were engaged in it. He touched the common currency of surgical thought and changed it into gold. For no effort of his was meaningless or sterile and all the powers of his mind and of his frail body were spent ungrudgingly in all his work. His well stocked library, and all new hterature were searched for him, and dispatches made for his assimilation. He worked as all great men should work, with a clean desk. His great powers were used for worthy purposes and in due season, nothing was wasted in mere hack work, for all that could be equally well done by others was left for them to do. Yet all his life he over- worked. He had an inner restless spirit which drove him at full speed. He must work, and while at work
THE MURPHY MEMORIAL ORATION 9
there was only one speed, the highest he could command. "I do not wish to hnger after my work is done" he said, and it was exactly what might have been expected from him.
It is useless to wish that men possessed of his quaUties and capacities should use themselves differently. A man must do as he must do. If we think that Murphy by spending himself with less lavish extravagance might have prolonged his life another ten years and so have achieved even greater results, to the benefit of all man- kind, we are pondering over one who was not Murphy, and who could not in those early fruitful years have been so avaricious for work, or have so generously poured forth the new truths of which he was at once both parent and missionary. Our designs for another man's life are but futile exercises of an imagination lacking in fuU un- derstanding, and adrift from realities.
Such, then, was Murphy as I knew him. It is easy now to see how great a figure he was in the world of surgery of his day. When all his work is reviewed, when not only its range, but the wonderful sincerity and the permanent and piercing accuracy of so large a part of it are considered; when we remember his unequalled gifts as teacher, his power of lucid exposition and of persuasive, or coercive argument, his devotion for many years at least to experimental research, it is no exaggera- tion, I think, to say of him that he was the greatest surgeon of his time. Great men are fitted to their times and in many respects are a reflex of them. But as their times pass their work is seen in far perspective and may appear to shrink in significance. It may then seem to have lost all its originahty, and boldness, and force, and we who stand afar off, untouched by the magnetism of a great
iO ESSAYS ON SURGICAL SUBJECTS
personality, marvel at its influence in its own day. For there are few indeed who enjoy both celebrity and fame. *'Mere talents are dry leaves, tossed up and down by gusts of passion and scattered and swept away; but genius lies on the bosom of Memory." How then wiU it be with Murphy? Judged by the standard of his contemporaries he was an intellectual giant, but of what stature will he be when judged by the standard of history? May I ask you to bear with me while I pass briefly in review some of the main features of the progress of surgery as science and art and teU the tale of some of the great men who have laboured in it, from earliest days up to the present time, so that at last we may see how Murphy stands and what figure he will make in the Great Procession.
The earliest remains of man known to exist shew that the art of the surgeon was practised upon him. Wherever skuUs of the Neolithic period have been dis- covered the openings made in them by the trepan are seen. Dr. Marcel Badouin, in 1908, found within a tomb dis- covered by accident at BeUeville the remains of 120 human beings. Eight of the skuUs had been trepanned, and the edges of the cut bones were smoothly healed over, showing beyond doubt that the patients survived the operation for periods long enough for this to be fully accomphshed. The disc of bone removed is supposed to have been worn as an amulet. The operation of tre- panning during the Neohthic period, was also performed in England, in Northern Africa, the Canary Islands, Mexico, and in Peru. It is performed today by the natives of New Ireland, to the east of New Guinea, by methods and with results apparently similar to those of the Neohthic age. Dr. Redman has presented to the Royal College of Surgeons of England a group of five skulls
THE MURPHY MEMORIAL ORATION U
shewing the effects of the operation, the instruments by which it is there performed, and the dressings appHed to the wound. And travellers tell us that the operation is still practised in the ancient way, so far as can be judged, by the Quichuas of Peru. Surgery is therefore as old an art as any.
Hippocrates was the first to give form and spirit to the practice of surgery. His observations even when con- sidered with the fuller knowledge of today often bewilder us by their accuracy, insight, and sagacity. His clinical methods judged by our modern standards were broad- based and structurally sound. He recognized not only the nobihty of the art of surgery, and the worthiness of its practitioners, but was well aware of the powerful influence which the craft must exert upon the science of medicine. The divorce of hand from brain which modern custom has worked hard to effect derived neither sanction nor authority from any words of his. As he deals with the outward shewing diseases his cHnical method is everywhere the same. He observes, reflects, weighs, and judges, con- siders his former experience of the like or analogous con- ditions; he suggests or discovers a general truth; he lays down principles for action, and he tells how the craftsman shall work. If the power of wide and accurate general- ization be, as I beheve it to be, among the supremest accompHshments of the human mind, then Hippocrates may in truth be said to have had few rivals, if indeed he has had any, among all those who in later times, and in all countries, have devoted themselves to the science of medicine. For by his injunctions as to the method of en- quiry into the conditions of a patient suffering from any disease he lays down for the first time the principles upon which inductive research is founded. He is the parent
12 ESSAYS ON SURGICAL SUBJECTS
not of medicine alone, but of the inductive method as apphcable to all branches of natural science. It is a proud claim that the method found its first apphcation in the science of medicine.
His observations upon cerebral injuries were hardly bettered until our own day, and many of his instructions as to their treatment cannot be neglected even now. He notes the effect of brain injuries upon the limbs of the opposite side. His work on fractures and dislocations has received praise from the greatest of critics. Littre spoke of it as "the grandest sm"gical monument of antiquity" and considered that the truth of its principles was eternal. A century ago the most eminent of French surgeons, Dupuytren, published a work on "Dislocations." Mal- gaigne, whose familiar name justly carries great weight, judged that, in respect of its discussion of congenital dis- locations, the work of Hippocrates was the richer and more accurate. The discourse of Hippocrates on "Wounds," which I read once again in the early weeks of the War, seems to have, in more relations than one, a bearing upon our bitter experience of those most grievous times. Certain it is that for 1500 years afterward nothing so apt was written, by no one were the essential problems of wound treatment so well understood. The dressings applied to wounds, he tells us, were to be of new materials; water, if not clean and sweet, was to be boiled and strained before use; care of the surgeon's hands and nails was thought most necessary. Oil and wine were the balsam for a bruised or dirty wound; or for one long neglected. The accurate apposition of the wound surfaces and the exclu- sion of air were means to secure rapid heaUng by "primary intention," which was clearly distinguished from "second intention." He dreaded amputation of a Umb, especially
THE MURPHY MEMORIAL ORATION 13
near the trunk: these operations today are in respect of their mortality still among the most lethal of all. As Sir John Tweedy has said, "The directions which Hippocrates gives concerning the arrangements of the operating room, the placing of the patient, the position of the assistants, the disposition of the lighting, the care to be taken of the sm'geon's hands, the need of ambidexterity, all indicate a careful and experienced practitioner." Hippocrates may count among his greatest glories that he recognized the essential unity of medicine and surgery, or rather that he did not distinguish between them: that he urged and practised the use of all means for the examination of the patient; that he saw no degradation as did so many later ages in the use of a physician's hands in the service of the individual patient, for whose welfare, as Aristotle said, all medicine exists. And his system, which embodied observation, reflection, judgment, all multiphed to make experience which shall decide right action, stands firm until this day. He knew its difiBculties, for he tells us that "experience is difficult, verification faUible, observa- tion long and costly, and occasion fleeting." There is one gap, however, a significant one in view of my later con- tention, in his method. He did not put matters to the proof by way of experiment. The experimental verifica- tion or denial of a suggested truth, or the new adventures in thought and action opened up by this method were not for him.
After Hippocrates we may take a long stride in point of time to the days of Celsus, who Hved in the reign of Augustus Caesar. It is interesting to remember that Celsus, the manuscript of whose work "DeRe Medicina" written about 30 A. D., was discovered in 1443 in the Church of St. Ambrose at Milan by Thomas of Sezanne,
iU ESSAYS ON SURGICAL SUBJECTS
afterwards Pope Nicolas V, was almost certainly not a physician. He was a noble of the family of CorneHi, who wrote works on medicine, agricultm-e, philosophy, law, and the art of war, in the spirit of an interested amateur. The deep prejudice of the patricians against the adoption, by one of their class, of medicine as a profession was un- conquerable. And the internal evidence in all his writings is opposed to the view that he could have practised as a physician ; he mocks at the value of medicine, and esteems the empirical methods of folk medicine as of equal interest and value to the academic methods of his time. He tells us that the true art of medicine lies in the correlation of theory and practice, the one guiding and controlling the other; speculation should guide thought but not deter- mine practice. References to surgical matters are found in all the books, but Books VII and VIII are devoted exclusively to the consideration of surgical matters. The great feature of these is that they record all the changes which had occurred in our art from the time of Hippocrates and especially informs us of the great attainments of the Alexandrian school in anatomy and surgery. He de- scribes wound treatment in detail; arrest of haemorrhage in a wound may be effected by packing and pressure, or by the ligature, which finds its first mention in his work. Sutures are to be used to secure apposition of wound sur- faces and edges, and, as a dressing, hnen bandages are to be soaked in wine, water or vinegar. He gives in sufiicient detail a description of operations for the radical cure of inguinal and umbilical hernia; and for the first time he refers to the removal of the testis as allowing a firmer and more secure closure of the inguinal canal. He mentions translucency as a test for hydrocele, and describes the tapping of dropsies. He quotes a large number of surgical
THE MURPHY MEMORIAL ORATION 15
authors, but among them all only Hippocrates is known to us.
It is evident that by the time of Celsus the boundaries of surgery had been sensibly enlarged, that old procedures had been bettered, as in amputations, and that many new ones had been devised. But progress had been along the old lines, and was achieved by the old methods. He recorded the multiplication and the magnification of old experiences rather than the revelation of new discoveries. He it was who gave us the fulfillment of the promise of the Hippocratic methods.
But great as were these methods, and considerable as was the success attending their appfication, there had been a slumber of the intellectual and philosophical aspects of medicine. Hippocrates had united in his own person many divergent and opposing tendencies; after his death there was an acceptance of his teaching by various sects, each adopting a part only, and dogmatism with its cramping tendencies crept in and the spirit of investigation died away. There was need now of a philosopher with new vision, and the need was supplied by Galen. Of Galen's life and character we know much, for he was vain and ambitious, garrulous and verbose. He was trained and deeply versed in all the current philosophies. A dream of his father, Nikon, interpreted as a vision from the God of Medicine, decided his choice of a profession. After the death of his father he wandered for nine years, studying in Corinth, Smyrna, and especially Alexandria, which then attracted commerce and patients from all parts of the world. His opportunities were great and his use of them unwearying. He wrote works on anatomical and physiological matters, and attained even in these early years of his a reputation for wisdom and
16 ESSAYS ON SURGICAL SUBJECTS
sagacity. For four years he lived in Rome. His learning, his industry, his friendship with the great and the noble, brought him high repute. But the envy of his colleagues, which he did much to provoke, was his downfall and he fled in fear of his life, to return on the invitation of Marcus Aurelius some twelve years later. But Galen's chief claim to honour, an imperishable one, is that he was the first of physicians to bring experiment to the aid of medicine. As Hippocrates was the parent of inductive method, so was Galen of the deductive. He was the first experimental physiologist. It was he who first discovered and described the cranial nerves, and the sympathetic nervous system; he divided the spinal cord and produced paraplegia; he severed the recurrent laryngeal nerve, and produced the hoarseness and aphonia, which are the constant results of this injury. He discovered the func- tion of a muscle by studying the loss of power which fol- lowed its division. He demonstrated the flow of urine from the kidney to the bladder along the ureters, by a series of experiments than which nothing today could be more conclusive. And he trembled at the very edge of a great discovery when he wrote: "If you would kiU an animal by cutting through a number of its large arteries you wiU find the veins becoming empty along with the arteries; now this could never occur if there were not anastomoses between them." Unhappily experiment alone did not content him, nor experiment in close aUiance with clinic£j observation. His knowledge of anatomy, unsurpassed by any of his time, did not keep him aloof from the wfldest speculations in natural philosophy. It is interesting to learn from him that the art of dissection was mainly, if not wholly, confined to certain famflies, among whom tradition and instruction give rise to a caste of
THE MURPHY MEMORIAL ORATION i7
dissectors. The members of a family were, from their childhood, exercised by their parents in dissecting, just as familiarly as in writing and reading, so that "there was no more fear of their forgetting their anatomy than of for- getting their alphabet."
Galen's dissections were confined to the bodies of animals, and the facts so discovered were appHed by anal- ogy only to the bodies of men. If a physiological hy- pothesis charmed him, his anatomical observations had to give way to it. His mind ran riot in speculation, often fan- tastic and far-fetched, but occasionally shewing a gleam of real insight, as, for example, in his belief that there was a close primary correspondence between the sexual organs of the male and female. But the evils were great and lasting. It was his rash conceits rather than the facts of his experiments, or his sound anatomical knowledge, and broad scientific purpose which were remembered, and indeed almost sanctified, by all men for a period of over 1500 years. Though he was the first of experimenters he asserted that speculation should lead experience and he exalted a debased metaphysics to a height exceeding that of strict and sober observation. In the times of intellectual stagnation in the Dark Ages the writings of Galen had an enequalled authority; and it was only by a notable independence that AbdoUatif dared to assert that anatomy was not to be learnt from books and that even Galen's observations were less to be trusted than the evidences of one's own senses. The result was the sterihty and the abasement of medicine until the experimental methods were revived by his direct intellectual descendant, WiUiam Harvey.
In a rather diflferent sense, and in a different scene, the great traditions of medicine were handed on by Avicenna,
18 ESSAYS ON SURGICAL SUBJECTS
who was born in Bokhara about 980 A. D. It was through him that the works of Hippocrates and Galen became widely known through the East, and finally filtered back to Europe through the Arabs and Moors at a time when learning and culture had almost vanished. The Arabian mind was essentially concerned with compiUng knowledge from all sources rather than in initiating enquiry; and a great and useful work, in this direction, was carried out by them during the brightest days of the Saracen Empire. The modern world indeed owes much to their careful preservation of knowledge and their multiphcation of copies of standard medical works, before the era of print- ing; even though the science and art of medicine in itself did not, through their efforts, advance one step. In Avicenna we find a mind as keen as that of his great predecessors, viewing the human body and its ailments in his own way, although numerous points of resemblance to the works of Galen and Hippocrates are everywhere evident. He was not an experimenter so much as a philosopher and the power of his mind over so many later centuries is probably to be attributed to his masterly grasp of all sciences as well as of medicine and surgery. In the art of surgery he can hardly have attained the skill of the great founder, as far as can be judged by the records in the Canon. We do not find all those evidences of mastership in technique which shine so strongly through the writings of Hippocrates. As is characteristic of the Eastern today the knowledge which he possessed and, to judge by the records of his successes, utihzed with great practical effect, was of a different order, both intuitive and logical, but intuitive before logical. His skill in deafing with fundamental mathematical problems is hardly surpassed at the present day, and in this respect he has been almost
THE MURPHY MEMORIAL ORATION 19
the only instance of a great mind applying mathematical concepts to medicine and surgery, up till the present era.
Of other writers before the sixteenth century, it is not unfair to say that they all, or almost all, were merely recorders, encyclopaedists it may be, but devoid of any spark of new thought or of wise generalization. They preserved with reverence the old tradition and the ancient knowledge, they discussed every device, and, at intermin- able length, the meanings of the old scriptures; they tortured new meanings out of old phrases, they were diligent in dressing old words new, and their scholarship was judged by their ingenuity, or infinite prolixity, in so doing.
The anatomists of the Middle Ages prepared the way for new enhghtenment. The oldest treatise on anatomy comes from Egypt. The papyrus dates probably from the reign of Thutmosis I, that is, from before the crossing of the Red Sea by the Israelites. It shews the heart with vessels proceeding from it, the hver, spleen, kidneys, ure- ters, and bladder. The first of comparative anatomists was Aristotle. The expedition of his pupil Alexander into Asia, which he accompanied, gave him unprecedented opportunities for the study of many animals; the result of his work is contained in several books. The first dissections of the human body were made by Erasistratus and Herophilus, of Alexandria. Under the Ptolemies in Egypt were garnered all the fading philosophies and sci- ences which amid the dissensions and distractions of life in Greece, could no longer flourish there. Alexandria then became the guardian and the host of all the sciences and the hteratures of the world. It was here, as we have seen, that Galen learnt much of his anatomy.
After the darkness of succeeding centuries the first
20 ESSAYS ON SURGICAL SUBJECTS
gleam of dawn was seen in the University of Bologna. For over 100 years it had been renowned as a centre of scholastic knowledge, of Uterature and of law. Mondinus, the father of anatomy as he is always acclaimed, lectured there between 1315 and 1325, and pubHcly demonstrated the structm'es of the body as disclosed by dissection. His descriptions are remarkable alike for their extent and their accuracy. The claim has been made for him that he went near to the discovery of the circulation of the blood, for he says that the heart drives or transmits the blood to the lungs. Two centuries later (1514-1564) was bom the greatest of all anatomists, Andreas Vesahus, a native of Brussels, a student at Lou vain. The difficulties of per- forming dissections were so great in France that he went to Italy for freer and larger opportunities. "My study of anatomy," he says, "would never have succeeded had I, when working at medicine in Paris, been wiUing that the viscera should be merely shewn to me and to my fellow students at one or another public dissection, by wholly unskilled barbers, and that in the most superficial way. I had to put my own hand to the business." When twenty-one years of age he was asked to lecture at the University of Padua. His original additions to the science of anatomy were numerous and of the highest importance. He swept away much of the old ' 'analogical' ' anatomy, the surmises and the errors, hoary with age, and sanctified by their free acceptance by a multitude of authors in the centuries after Galen formulated them. His work on anatomy is adorned with illustrations which for beauty of design and accuracy of execution have never been surpassed, indeed, I think not equalled, since they were pubfished. It is said that the figures were drawn by Titian. Cuvier remarks that if this be not true they
THE MURPHY MEMORIAL ORATION 21
must at least be the work of one of his most distinguished pupils. But Vesalius did something more than all this. He was the first imitator of Galen in experimental work, and though he did little enough, it was sufficient to show that the method was not utterly forgotten. He was the forerunner of those distinguished Itahan anatomists who may share with him the credit for the creation of the science of anatomy, of Eustachius, of Fallopius, who in his short life labored to great ends, and of Fabricius, his successor in the chair of anatomy and surgery of Padua, among whose pupils was William Harvey. The presence of folds in the interior of some veins had been noted by Sylvius and Vesahus and others, and those of the vena azygos were particularly described by Canani in 1547, but it was Fabricius who recognized the existence of valves throughout the venous system and who observed that they were all turned towards the heart.
Harvey had been attracted by the fame of Fabricius to Padua, at a time when Gahleo was teaching and was en- gaging in those methodical researches whose influences have lasted to our own day. Harvey said of himself that he felt it in some sort criminal to call in question doctrines that had descended through a long succession of ages and carried the authority of ancients, but he "appealed unto Nature that bowed to no antiquity, and was of still higher authority than the ancients." It was at the instigation of Fabricius that Harvey undertook by experiment to dis- cover the function of the valves in the venous system, and in the year of Shakespeare's death those experiments whose end was to bring about the greatest discovery in the history of medicine were begun. The discovery had almost been made by half a dozen of his predecessors who appeared to haye stood upon its very brink. As Cuvier says, we are
22 ESSAYS ON SURGICAL SUBJECTS
often on the edge of discovery without suspecting it. There can be Httle doubt that the puhnonary circulation had been recognized by the unhappy Servetus, who, with his works, was burned as a heretic at Geneva in 1553 by Calvin.
In 1559, a pupil of Vesalius at Padua, Realdus Colum- bus, may be said to have suggested the existence of this circulation by inductive reasoning, but to ingenious speculation the minds of men were hardened. It was open demonstration and proof that were needed to press home an opinion so contrary to all accepted teaching.
A discovery is rarely, if ever, a sudden achievement, nor is it the work of one man ; a long series of observations each in tm*n received in doubt, and discussed in hostility, are famiharized by time, and lead at last to the gradual disclosure of the truth. Harvey's discovery was finally due to his application of the experimental method of Archimedes and Galen to a problem of which many of the factors were gJready known ; or, as he himself tells us, the circulation of the blood was held to be completely demonstrated by experiment, observation, and ocular inspection against all force and array of argument. He writes: "When I first gave my mind to vivisections, as a means of discovering the motions and uses of the heart and sought to discover these from actual inspection and not from the writings of others, I found the task so truly arduous, so full of difficulties, that I was almost tempted to think with Fracastorius, that the motion of the heart was only to be comprehended by God. ... At length and by using greater and daily dihgence, having frequent recourse to vivisections, employing a variety of animals for the purpose, and collecting numerous observations, I thought that I had attained to the truth."
THE MURPHY MEMORIAL ORATION 23
The reception of this discovery was generous at home ; tardy and reluctant, or openly hostile abroad. But it was everywhere eagerly and hotly discussed. Harvey says: "But scarce an hour has passed since the birthday of the circulation of the blood that I have not heard some- thing for good and for evil said of this my discovery. Some abuse it as a feeble infant, and yet unworthy to have seen the hght; others again think the banthng de- serves to be cherished and cared for. These oppose it with much ado, those patronize it with abundant com- mendation."
Biolan, distinguished as an anatomist, and professor at the College de France, denied and derided it. What Harvey felt of the opposition may be learnt from his reply to a friend who urged upon him the pubHcation of his later work, De Generatione Animalium: "And would you advise me to quit the tranquillity of this haven, wherein I now calmly spend my days and again commit myself to the unfaithful ocean? You are not ignorant how great troubles my lucubrations, formerly pubUshed, have raised. Better it is certainly, at some time, to en- deavour to grow wise at home in private than by the hasty divulgation of such things, to the knowledge whereof you have attained with vast labour, to stir up tempests that may deprive you of your leisure and quiet for the future." Nevertheless, compensations and rewards came to him in full measure, and he had the satisfaction of Hving to see the general acceptance of his discoveries. This dis- covery, as Whewell said, implied the usual conditions, distinct general notions, careful observation of many facts, and the mental act of bringing together these elements of truth. Boyle wrote: "I remember that when I asked our famous Harvey what were the things that
24 ESSAYS ON SURGICAL SUBJECTS
induced him to think of a circulation of the blood, he answered me that when he took notice that the valves in the veins of so many parts of the body were so placed that they gave a free passage to the blood toward the heart, but opposed the passage of the venal blood the contrary way, he was incited to imagine that so provident a cause as Nature had not placed so many valves without design ; and no design seemed more probable than that the blood should be sent through the arteries and return through the veins whose valves did not oppose its course that way. That supposition his experiments confirmed."
But the experimental methods of Galen, revived by Gilbert, physician to Queeen Elizabeth and the father of modem experimental science, and practised with such supreme effect by Harvey, was to find as yet no place in scientific surgery. That art it is true was practised with wider scope, with confidence bred of generations of experience, and with a risk that was perhaps steadily, though almost neghgibly, diminishing. Safety was rather dependent upon the individual capacity of the surgeon than a quality common to the work of all. Richard Wiseman, who was born three years after the pubHcation of Harvey's discovery, is generally granted the proud title of the Father of English surgery. He was a man "given to the observation of Nature" and became Sergeant Surgeon to Charles H and to James H (who when Prince of Wales and Duke of York were withdrawn under a hedge during the battle of Edgehill, October 23, 1642, when Harvey distracted their thoughts by reading to them), and among his contributions to the craft of surgery may be mentioned his operations for hernia, and his advocacy of primary amputation in cases of injury, by gunshot or otherwise, of the limbs.
THE MURPHY MEMORIAL ORATION 25
Ambrose Pare was to French surgery what Wiseman was to British. The life of Pare is one of the greatest romances in the history of our profession; it tells the story of the progress of the son of a joiner who was groom, gardener, barber's apprentice, until he became at last the surgeon to four kings of France. It was he who was concealed, locked up in a room of the Louvre, and spared from death by special order of Charles IX at the Massacre of the Huguenots on the day of St. Bartholomew. For the King said that it was not reason- able that a man who was worth a whole world of men should be murdered. He is the outstanding medical figure in the Renaissance. He was untaught and there- fore in youth at least free from the tranamels of ancient lore. Early in life he said : "I make no claim to have read Galen either in Greek or in Latin; for it did not please God to be so gracious to my youth that it should be in- structed either in the one tongue or in the other." At last when he read Hippocrates and Galen he surpassed them both in the niunber and variety of the conditions he had been called upon to treat; and he was therefore the better fitted to approach their teaching in the spirit of an informed and practised critic. "We must not be drugged by the work of the ancients as if they had known all things or spoken all," he writes. Yet in later years he studied dihgently, for he was said by Thomas Johnson, who translated and edited his works, to be "a man very well versed in the writings of the ancient and modem physicians and surgeons." He was one of the greatest original minds our art has known, fearless, independent, alert and inventive, and not without a good conceit. "There be few men of this profession," he writes, "which can bring so much authority to their writings either with
26 ESSAYS ON SURGICAL SUBJECTS
reason or experience as I can," and again, "I have so certainly touched the mark whereat I aimed that antiq- uity may seem to have nothing wherein it may exceed us beside the glory of invention, nor posterity anything left but a certain small hope to add some things as it is easy to add to former inventions." He won for surgery and for those who practised the craft in France a place they had never before attained.
Surgery was still lacking its firm foundation in patho- logical anatomy. This was to be built by Morgagni and John Hunter and by many others taught and inspired by them. The tireless industry, unwearying care, and pro- found sagacity of John Hunter gave to an art that was largely empirical a warrant based upon a sound knowledge of morbid processes in all tissues. He was observer, investigator, collector, in each capacity without a rival. He was unceasing in his search for truth by way of ex- periment. "Don't think, try the experiment," he urged his pupil Jenner. In his own person he did both su- premely well. His disregard of the written word was deplorable no doubt, but refreshing after so much b£U"ren speculation among his forerunners. *T am not a reader of books," he said; and again, "I beheve nothing I have not seen and observed myself." His rebuff to one who accused him of ignorance of the classics is famous: "Jesse Foot accuses me of not understanding the dead languages, but I could teach him that on the dead body which he never knew in any language, dead or Hving." Often he recounts the details of an experiment, but leaves us to draw the conclusion. He changed the whole spirit of practice and placed knowledge on the throne of authority. The day was gone forever when a pure and dangerous em- piricism could be practised ; surgery became a science and
THE MURPHY MEMORIAL ORATION 27
its craft a rational procedure. The museum which he founded and which still bears his name in the Royal College of Surgeons of England is unsurpassed in all the world, and his own specimens are still to be seen to bear witness to his incomparable services to pathological anatomy. For Morgagni no praise can be too high. His letters may be read today with dehght; though his knowledge of disease is, in the modern view, often steeped in mediaeval- ism, his long array of facts and of relevant instances, his description of morbid parts, his accurate and searching generalizations are among the greatest contributions to medical literature in all the ages.
Such was the progress of surgery up to the early years of the nineteenth century. The discovery of the anaes- thetic properties of ether and chloroform completely changed the possibihties of the range of appHcation of surgery to morbid conditions and enlarged also the scope of experimental work upon animals. But in every direc- tion the surgeon's work was hampered and frustrated by the occurrence of infection and all its dire consequences, in the majority of the wounds inflicted. It was for Lister that the world was waiting and his coming changed every- thing. For, as Carlyle said, *'The great man was always as lightning out of Heaven : the rest of men waited for him hke fuel, and then they too would flame."
Lister, as every one knows, introduced the antiseptic system into surgery. Before his time the wounds inflicted by the surgeon, or those received in civil life as in cases of compound fracture, became septic almost as a matter of course. The decomposition of the wound discharges was formerly held to be due to contact with the oxygen of the air. Lister recognized that the investigation of many observers, ending with Pasteur, which shewed that far-
25 ESSAYS ON SURGICAL SUBJECTS
mentative and putrefactive processes depended upon minute organisms, were applicable in surgical work also. In the year 1836, a French observer, G. Latour, had pointed out that the tiny particles of which yeast was composed were capable of multipUcation, that they were in fact £dive, and that it was by their propagation that the change known as fermentation, the change of sugar into alcohol, was produced. Both Latour and T. Schwann shewed that this process could be suppressed by the appHcation of heat to the yeast. Schwann, especially, called attention to the fact that the putrefaction of organic substances was due to these minute living bodies, and that putrefaction and fermentation were essentially one. The weighty authority of Liebig was opposed to this view, and Helmholtz, after a time of wavering, finally ranged himself against Schwann. It was in 1856 that Pasteur began the series of experiments which demon- strated finally that micro-organisms were the cause of fermentation and of putrefaction, and that for each form of fermentation studied by him — yeast fermentation, lactic acid fermentation, butyric acid fermentation — there was one specific cause, and only one.
Lister had long been working on the problem of in- flanmiation and of the decomposition of wound discharges. When, therefore, early in 1865 he read of the work of Pasteur his mind was prepared to receive the new evidence, and to put it to the proof in the treatment of surgical cases. It is impossible for us now to realize the horrors and the mortahty attached to surgical work at the period when Pasteur's papers were written. In almost every case the discharge from a wound underwent putrefaction; inflammation of varying degrees of severity attacked the wounds, pus poured from their surfaces, and hospital
THE MURPHY MEMORIAL ORATION 29
gangrene, erysipelas, and pyaemia, the most desperate form of blood poisoning, occurred with terrible frequency. The clean healing of a wound by "first intention" rarely occurred. A surgeon was more than content, he was eager and gratified, to see a thick creamy discharge of "laudable pus" from the surfaces of a wound. Very few operations were performed, and then, as a general rule, only in cases where death or extreme disabihty was other- wise certain. Limbs were amputated when smashed, or diseased as to be worthless and dangerous; the mortafity from amputations varied from 40 to 50 per cent. In Lister's hands, up to the year 1865, in 15 cases of excision of the wrist-joint by his own method, 6 patients suffered from hospital gangrene and 1 died from pyaemia. Volk- mann, one of the earhest of Lister's disciples, had results so ghastly that he decided to close his hospital altogether for some months. Lister's own account of his wards at Glasgow is disturbing and distressing even today. The most vigorous and robust patients were swept away after the most trifling injuries or operations, and septic diseases were so frequent and so deadly that the very name of hospital was dreaded by every sufferer. John Bell, a great surgeon, spoke of the hospital as a "house of death." In the paper which Lister had read, Pasteur asserted that "the most far reaching of my researches is simple enough, it is that putrefaction is produced by hving ferments." He asserted that the oxygen of the air was not the cause of putrefaction, as everyone hitherto had supposed; that indeed some of the causes of decomposition could thrive only in the absence of oxygen. This ob- servation, which distinguishes "aerobic" from "anaerobic" organisms, is of the first importance. Lister at once reahzed the significance of this work in connection with the
30 ESSAYS ON SURGICAL SUBJECTS
changes occurring in wound discharges and on wound surfaces. In 1867 he wrote: "When it had been shewn by the researches of Pasteur that the septic property of the atmosphere depended not on the oxygen or any gaseous constituent, but on minute organisms suspended in it, which owed their energy to their vitality, it oc- curred to me that decomposition in the injured part might be avoided, without excluding the air, by applying as a dressing some material capable of destroying the life of the floating particles." He proceeded to make trial of the hypothesis in his own work. At this time he had heard also of the experiments made at Carhsle with the disinfection and deodorization of sewage by German creosote, a crude form of carboHc acid. The administra- tion of a very small proportion of this substance not only prevented all odour from the lands irrigated, but destroyed the entozoa which usually infest cattle fed upon such pastures. This was the preparation he decided, after trying chloride of zinc and the sulphites, to rely upon in his early trials.
Among surgical cases then, as now, the sharpest distinction was drawn between simple and compound fractures; between fractures, that is, where the soft parts are almost unhurt and the skin unwounded, and frac- tures in which a wound through the skin and soft tissues reaches the broken ends of bone. In simple fractures, life was rarely or never in jeopardy; in compound fractures, putrefaction of wound discharges occurred, septic proc- esses became rampant and the mortality was high. "The frequency of disastrous consequences in compound frac- tures, contrasted with the complete immunity from danger to life or Umb in simple fracture, is one of the most striking as well as melancholy facts in surgical practice.'*
THE MURPHY MEMORIAL ORATION 31
These were the opening words of Lister's first paper on the "new methods" in the Lancet in 1867. The first trial of this method proved disastrous owing to improper management, but the second attempt, on August 12, 1865, proved perfectly satisfactory, and was followed by others which more than reahzed Lister's most sanguine expectations. Compound fractures healed and united as easily and quickly, and almost as safely, as simple frac- tures. The method proved by so stern a trial was soon applied to cases of chronic abscess, and by degree to opera- tion wounds. In one of his earher papers Lister wTOte: "Admitting then the truth of the germ theory and proceed- ing in accordance with it, we must when dealing with any case destroy, in the first instance, once for all any septic organisms which may exist within the parts concerned; and after this is done, our efiforts must be directed to the prevention of the entrance of others into it." This state- ment shews that Lister laid down the two essential principles of antiseptic system, the prophylactic and the therapeutic.
Lister's work, it is evident, was the result of research carried out both by the inductive and by the deductive method, and tested and confirmed by many experiments. He combined in full measure the wide, patient, penetrating inquiry, the comprehensive generalization, and the sound wisdom of the method of Hippocrates, with the demand for experimental illumination or proof afforded by the method of Galen, of Bacon, and of Harvey. He combined in his own work the best of all the schools, and it was no accident that the greatest of all discoveries relating to the science and the art of surgery was made by him.
If a man's services to humanity are the standard by which we measure his value, then Lister may be counted £is
52 ESSAYS ON SURGICAL SUBJECTS
perhaps the greatest man the world has ever produced. For he has been the means of aboHshing, or assuaging, the sufferings of men and women to a degree which is quite incalculable, and, as I said of him years ago, he has been the means of saving more lives than all the wars of all the ages have thrown away.
As the result of Lister's work the way was cleared for an immense and immediate advance in surgical practice, and for an extension into regions that before had been denied even to the most intrepid surgical adventure. The result is known to all the world. Diseases which were beyond the reach of any are now within the grasp of all surgeons. Operations whose mortahty even twenty-five years ago was so heavy as to be almost prohibitive are now performed with a frequency and with a degree of safety which never cease to excite our wonder. But Lis- ter's work did something else; it shewed how research for the future must be conducted if our progress were to be both enterprising and safe. It shewed that clinical research and experiment must forever run together.
The achievements of chnical research have been gigantic since Lister's day. The safety which he brought into all our work resulted in an advancement, httle by little, of the attack upon the diseases of internal organs, and it exercised in consequence a very powerful, germinal influence upon internal medicine. If our knowledge of the disease of the abdominal viscera of thirty years ago is compared with that of today the truth of this statement wiU appear. In connection with the diseases of the gall- bladder and bile-ducts the work of Courvoisier published in 1890 is a complete record : it is, indeed, one of the most monumental works ever produced in surgical Hterature. What was known then, in comparison with now ? Nothing
THE MURPHY MEMORIAL ORATION 33
of the early symptoms of gall-stones, of the relation be- tween them and visceral and other infections, nothing of the symptoms due to the impaction of stones in one or other of the ducts; almost nothing of the possibihties of safe rehef by surgery. Lister's work has not only been the means of relief to the patient in his agony, but has been the instrument by which our own most prolific en- quiries into the symptomatology, etiology, and, in no in- significant degree, the pathology of this disease has been made. Of gastric ulcer as distinguished from cancer of the stomach our knowledge thirty years ago was trivial compared with what it is today. Much of the teaching of those days is not confirmed by the surgical enquiries of today; and it is now I suppose admitted universally that unless the physician is guided by the principles of diagnosis discovered by the surgeon and the radiographer he will stray wide from the path of truth. So, too, of duodenal ulcer, our present knowledge of which is due entirely to the chnical research made possible by safe surgery. And the Hst might be greatly extended. Much more remains to be done. We are only on the threshold of our enquiries as to the complementary action of one organ upon another; of the relations, for example, of the pancreas, spleen, and liver to each other; and of all or any of these to parts, or to the whole, of the alimentary canal, and to the organs possessed only of an internal secretion. CHnical research involves and implies the fullest enquiry into the detailed character of all present symptoms; the most searching pursuit after those earliest departures from smooth and normal action which observa- tion can discover, the correlation of all these with the manifest changes observed at all stages in the several
organs during operations upon any of them. When all 3
3U ESSAYS ON SURGICAL SUBJECTS
this knowledge has slowly and patiently been garnered, then the method of experiment must be used to carry our enquiries still further, and to help us to answer the ques- tion: "How do these things happen?" CHnical research will tell us of the changes in other organs associated with the one to which our main enquiry is directed, but a process of deduction and an enquiry by experiment are necessary before we can disclose the sequence of events which culminate at last in the disease we set out to study. The chnical research, is beyond question, the more arduous. The factors which enter into it are so many, so variable, so impressed by the changing conditions and moods and circumstances of the patient that only the most inde- fatigable patience and the most trained capacity can help to resolve the matter into simple terms, to dissociate what may be an infinitely complex grouping of many facts before we can rearrange them in appropriate sequence of process or of time. We must discover the "usual conditions," obtain our general notions, observe carefully a multitude of facts, arrange them in orderly fashion, employ the mental act which will bring them together as elements in a great truth. When this is done, and only when this is done, can the deductive method of Galen be employed to fullest advantage. Experimental re- search is not so baffling a task. Great ingenuity in the devising of experiments may be found in the supreme masters, Pawlow, Almroth Wright, and a very few others. But each experiment often contains only the one question to which the answer is sought. The answer is "yes" or "no," or is expressed in simple terms, and it is free from those infinite perplexities and changing proportions which distinguish the answer given to any enquiry, even the simplest, in the method of clinical research. When in a
THE MURPHY MEMORIAL ORATION 35
simple experiment the answer is given, a new problem may arise suggesting a tother experiment. Thus a chain of experiments may develop each of which answers not only its own question, but contributes in its own degree to the final answer embracing the entire sequence of experiments. The single experiment may be simple. But in respect of a series, each member of which is dependent upon its predecessor, and provokes its successor, and all of which illuminate or decide some problem suggested by chnical research, nothing has been done in surgery comparable to that which in chemistry has been achieved by Fisher and Abderhalden.
These brief glimpses at the progress of surgery shew that its epochs may be considered as three in number.
In the first and longest the writings of Hippocrates and Galen were regarded as an inspired gospel. By them the minds of men were held captive, and their imagination enslaved, and every new adventure in thought or action suppressed or cramped. To seek in them for knowledge was all the effort of every man. What was written in them was truth, what was outside them rank heresy. Where the meaning was not as plain as day the most endless enquiry and discussion ensued. The controversies which then shook the intellectugd world to its very founda- tion are seen now to be only laughable, both in their methods and in their quaint decisions. In later ages to challenge the truth or the final revelation of any teaching of Galen's was almost blasphemous, and it required a rare and reckless courage to say, as did Henry of Mondeville, "God did not surely exhaust all his creative power in making Galen." The prophets and seers, who Httle by httle, and with very needful caution, led the world through this black night, death's second self, into the dawn, were
36 ESSAYS ON SURGICAL SUBJECTS
the anatomist Mondinus, Vesalius, Fabricius, Fallopius, and others. By their work the assertions of the old scriptures could be openly gauged. In gross anatomy a structure stands out for all to see. If Galen's teaching denied the truth disclosed by dissection it was most gently and tentatively refuted, heretical and perilous as such a work might be. And as normal anatomy grew it was joined by morbid anatomy, and at last came Morgagni and Hunter. They established the second great era in which the pathology of the dead was studied with a wealth of care and inexhaustible patience. The gross lesions of morbid anatomy, and even many that were recondite and remote, were examined, described, dis- cussed, and arranged in due order by a mighty succession of able men, whose work today we too Hghtly neglect. Clinical medicine and surgery were dominated by the knowledge of the morbid processes discovered in this time. Symptoms were correlated with the signs found upon the postmortem table and upon the shelves of museums. Chnical histories were largely devoted to terminal con- ditions, for it was only these that brought a patient to a hospital where he died, and where an autopsy could be made. But patients do not die in hospital from the dis- eases from which they suffer long during life. And in consequence severe Hmitations were set to our knowledge of disease of all kinds.
Lister's work made possible the third era which de- pended for its swift and notable advance upon a study of the pathology of the Hving, upon a study, that is, of morbid processes in their course rather than when their race was fully run. By multiplying observations made during operations we learnt, httle by httle, how to capture a general truth from a series of individual exam-
THE MURPHY MEMORIAL ORATION 37
pies. By slow degrees and grudgingly it was admitted that terminal manifestations of disease and the advanced ravages of morbid anatomy did not constitute all medi- cine; that earlier symptoms were to be referred to earlier changes in organs exposed during the course of operations. And these changes and symptoms we now reahze are themselves but late; still earlier manifestations of aber- rant action are being sought patiently and with a success that holds increasing hope for future work.
During all these three periods, through Galen, Vesahus, Harvey, Bacon, Hunter, Lister, there has run a vein of experimental work, testing hypothesis and discovering new truths. Since Lister's day there has been a steadily increasing recognition of the value of such work and of the urgent necessity of continuing it, of enlarging its field so that it may be coterminous with medicine itself. We are, indeed, newly entered upon another stage, the stage of combined research, in which clinical observation, in- ductive and deductive processes of reasoning, and ex- perimental enquiry are Unked together. In its progress, so far, the work of a few men stands out as of the utmost significance. Horsley's work upon myxoedema, cretinism, and on the functions of the thyroid gland; Ferrier's, Macewen's, and Horsley's researches upon cerebral affec- tions and cerebral locahzation; Senn's work upon the pancreas and upon the intestines; Kocher's work upon cerebral compression and upon the thyroid gland; Crile's work upon shock and upon blood transfusion ; and Harvey Cushing's work upon diseases of the brain and the pitui- tary gland. Since Lister rid all operations upon man and upon animals of their former terrors, many surgeons have turned to experiment in order to perfect and to illustrate their own work, to test an hypothesis, to search for new
38 ESSAYS ON SURGICAL SUBJECTS
procedures or to discover an explanation of clinical phenomena whose meaning was difficult to unravel. In recent days few men have displayed so vast a range of clinical interests, so keen a zest for relevant experimental enquiry, so logical a mind, such frank intellectual honesty as Murphy. He may justly be ranked as one of the earliest and one of the greatest exponents of the method of combined research.
Murphy's first work to attract the attention of all surgeons was that which led him to devise and to perfect the most exquisite surgical implement that has ever been invented, "Murphy's button." Up to the time at which experimental work on the anastomosis of hollow abdominal viscera was begun by Senn, Murphy, and others, the method of securing union was difficult, tedious, and un- safe. I well remember to have seen the operation of "pylorectomy" done in the year 1889. A very niggardly removal of a small "prepyloric" carcinoma was made, and the cut end of the duodenum was united to a part of the divided end of the stomach after the first method of Bill- roth. We counted over two hundred sutures used to effect the junction. Each suture was of silk; for each the needle was separately threaded, the suture passed, tied, and cut; a wearisome total of movements of the surgeon and his assistants, involving a great expenditure of time. No wonder the surgeons searched for simpler methods. Senn's bone plates, the first mechanical apparatus to assist in an anastomosis, were ingenious instruments not very easy to use, requiring a not inconsiderable degree of skill and patience to secure, that the threads holding them were well and truly tied, and calHng also for the introduction of a number of additional sutures. The results following the use of these instruments were some-
THE MURPHY MEMORIAL ORATION 39
times very good and sometimes very bad. While surgeons were struggling with this tiresome and unsatisfactory implement, Murphy introduced his "button." It was the result of a great deal of experimental work done upon dogs, in the early hours of the morning, and in the lean years of his early married Ufe. In this work Mrs. Murphy took her share, giving chloroform to the animals. A few people were privileged to know of the boundless help and inspiration which Mrs. Murphy gave her husband in those hard, but happy days when he was struggling for his place in the world of surgery. His wonderful success was in no small way due to her sympathy, encouragement, £uid un- faltering behef in him; and to the eager enthusiasm which she shewed in all his work. His fame was her fame also. As I offer to him my tribute of laurel for honour and of rosemary for remembrance, it is an added pride that I can do so in her presence. With the help of Murphy's button operations which had been difficult and perilous at once became so simple that the merest tyro could perform them, and the risk of all operations fell with amazing rapidity. The button was used in every cUnic and upon all occa- sions where visceral anastomoses had to be effected; and the name and the fame of Murphy travelled round the world. But I still think that the great virtue of the button was not in its own direct use, but in the convincing demonstration it gave to us of the essential simplicity of the process of visceral union. By using the button we learned how safely and how rapidly the peritoneal junc- tion took place; there was no need, it was now perfectly evident, for the hundreds of stitches that all surgeons were using. Firm, even approximation for a very few days would lead, the button showed beyond a doubt, to a permanent and secure fusion of the apposed viscera.
40 ESSAYS ON SURGICAL SUBJECTS
The button itself was occasionally a danger. After the operation of gastro-enterostomy it sometimes remained for many months in the stomach ; when it passed on to the lower intestine it might cause obstruction, or it might ulcerate its way through the intestinal wall. We learned from the use of the button not that the button itself should be used, but all the secrets of the principles of entero-anastomosis. It is not the least exaggeration to say that Murphy revolutionized the methods of visceral anastomosis, and was partly responsible for giving that impulse to abdominal surgery which in later years has carried it so far.
A characteristic example of his method of approach- ing a surgical subject to which he desired to contribute is shewn in his work on "Ankylosis," which he began in 1901. Up to that time the treatment of stiff joints was unsatisfactory, and in cases of severe ankylosis, whether bony or densely fibrous, was almost hopeless. Murphy says he proposes to begin the study of his subject by some questions: "What are joints? What is the embryology of joint formation? What is the pathological histology of aquired arthoses, of false joints? What is the pathology of hygromata? (acquired endothehal fined sac) Can they be produced artificially? What is ankylosis? What are the pathologic and anatomic changes included in the term? What tissues are involved? From a practical standpoint, into what classes may it be divided? When ankylosis has formed, what are the limitations of surgery for its refief? Can we re-establish a movable, functionating joint with synovial lining? Can we restore motion, and to what degree? In what class of cases can the best results be secured? Can we for the future
THE MURPHY MEMORIAL ORATION Ul
promise better than the flexible, fibrous unions that we have secured in the past?'*
He then discusses the development of joints in the embryo, and the method of bursa formation in early and in adult fife, shews that hygromata and ganglia are the products of the liquefaction of hypertrophied connec- tive tissue, and indicates that in an artificial development of joints all the facts relative to these processes should be utihzed. The formation of "false joints" as a result of non-union in fractures of the long bones led to the recognition of the pathological condition whose counter- part was provoked in the operation of arthroplasty, in which a foreign body was inserted between the end of bones separated at an ankylosed joint, to prevent re- union and to cause the development of a new joint. He then investigates the matter by experiments upon dogs, and proceeds to demonstrate its efficacy upon men afflicted by bony ankylosis of their joints. The whole piece of work is an exemplary instance of the combination of clinical experience and of experimental research leading to the establishment of a new method of treatment in a severe and most disabfing condition.
In 1897, Murphy pubhshed his article, "Resection of Arteries and Veins Injured in Continuity. End-to-End Suture; Experimental and Chnical Research," in which for the first time he estabhshed the principles, and described one of the methods, of arterial suture and anastomosis. As in other articles, chnical needs indicate the fines of his experimental enquiries; and a widening of the bounds of surgical endeavour and practice is the result. In 1898, he defivered at Denver the Oration on Surgery before the American Medical Association and chose as his subject the "Surgery of the Lungs." Independently
42 ESSAYS ON SURGICAL SUBJECTS
of Forlanini he suggested the injection of nitrogen into the pleural cavity in cases of hopeless unilatergd disease of the lung. No enthusiastic acceptance greeted the suggestion. Murphy himself extended the method in his later work to cases of incipient tuberculous disease ; and recent experience has fully justified all his claims and has given sanction to his methods. He again combined clinical experience and research by experiment in his work on "Surgery of the Spinal Cord," pubHshed in 1907, and his final summary on neurological surgery in Surgery, Gynecology, and Obstetrics, 1907, iv, 385, was the most accurate and concise survey of our knowledge of this sub- ject which had then been pubHshed.
Wherever we turn we find his method to be the same. A wide survey of the subject to be discussed made in- teresting by the personal magic that he was able to throw into it; a disclosure of the gaps in our knowledge; a sug- gestion as to the means by which that knowledge or a want in our technical methods can be made good ; a record of experiment to elucidate or to solve a difiicult point; a wealth of cHnical observation and a formidable array of arguments, lead to an inevitable conclusion stated in terms that none could fail to comprehend. In every article of his that we read we can see the working of an orderly mind, of a mind most eager for new truths, and expectant of them. For every subject he seems to have a mental scaffolding by which he guides and arranges the truths as they are fashioned and duly laid in place. He had a zeal for classifications which looked complex, but when carefully considered tended to simpficity and to easy and ready remembrance. Of his other surgical work and of his high-minded endeavour to seek for and to secure the purity and advancement of his own profession
THE MURPHY MEMORIAL ORATION ^
I need say nothing. It is a record of sincere and honest devotion to his duty as he saw it before him. Great deeds are born of great zeal and high resolve; and he was lacking in neither. All that he did is within the recent memory of his colleagues here. My immediate purpose has been fulfilled if I have sketched, however roughly, the giant figure of the man and the surgeon whose work was done among you and whose fame has spread out into all lands.
Our calKng by common consent, the noblest of any, dignifies all who join its ranks. The honour of the pro- fession is the cumulative honour of all who both in days gone by and in our own time have worthily and honestly laboured in it. In every generation there are a chosen happy few who shed a special lustre upon it by their character, their scientific attainments, or the great glory of their service to their fellow men; for it is, as Ambrose Pare said, "beautiful and the best of all things to work for the refief and cure of suffering." In our generation Murphy was one who by his full devotion, his complete surrender to its ideals, and by his loyal, earnest, and un- ceasing work, added distinction to our profession, which, in return, showered upon him the rewards with which no others can compare, the approbation of his fellow workers and the friendship and trust of the best among his con- temporaries in every country.
"The mightier man, the mightier is the thing That makes him honom'ed."
As we look backward upon the long history of the science and art of medicine we seem to see a great proces- sion of famous and heroic figures, each one standing not only as a witness of his own authentic achievements, but
44 ESSAYS ON SURGICAL SUBJECTS
also as a symbol of the traditions, ideals, and aims of the age which he adorns. The procession is sometimes thinly stretched out, or even rudely broken here and there, but in happier ages it is thronged by an eager and exult-, ant crowd. In medicine the whole pageant is as noble and splendid as in any of the sciences or arts, and it reveals the collective and continuous genius of a band of men inspired by the loftiest purpose, and lavish in labour and sacrifice for the welfare of mankind. They have come throughout the ages from every land. They now belong not to one country but to every country, for they are the common possession and the pride of all the world. They have lost their nationahty in death. They are men whose deeds will not be forgotten and whose names will live to all generations. Among such men, few in number, supreme in achievement, John Benjamin Miu-- phy is worthy to take his place.
THE RITUAL OF A SURGICAL OPERATION*
Every operation in surgery is an experiment in bac- teriology. The success of the experiment in respect of the salvation of the patient, the quality of heahng in the wound, the amount of local or constitutional reaction, the discomforts during the days following operation, and the nature and severity of any possible sequels, depend not only on the skill but also upon the care exercised by the surgeon in the ritual of the operation. The "ritualist" must not be a man unduly concerned with fixed forms and ceremonies, with carrying out the rigidly prescribed ordinances of the surgical sect to which he owes allegiance; but a man who, while observing with unfaltering loyalty those practices which experience and experiment have together imposed upon him, refuses to be merely a mimic bound by custom and routine. He must set endeavour in continual motion, and seek always and earnestly for simpler methods and a better way. In the craft of surgery the master word is simpHcity.
The ritual of an operation commences before, some- times long before, the incision is made, and may continue for a long period after the wound is healed. In the transi- tion of a patient from ill health to sound health the opera- tion itself is only one — though it may be the most im- portant— of all the factors concerned in this fortunate event.
* Remarks made at the opening of a discussion at the first meeting of the British Association of Surgeons, held at the Royal College of Surgeons, May 14, 1920. Reprinted from The British Journal of Surgery, Vol. VIII, No. 29, 1920.
^6 ESSAYS ON SURGICAL SUBJECTS
In this discussion we are not asked to deal with two essential preliminary propositions, the necessity for the most careful clinical inquiry into all aspects of the patient's history and condition, so that accuracy of diagnosis may be achieved before operation; and the exact relevance of the proposed operation in the particular conditions rec- ognized by this inquiry, or discovered during the course of the operation itself. A great many mistakes are still made in both these matters. It is useless, to say the least, to perform the most perfect technical operation in conditions which do not call for it; and the test of a successful operation is not restricted to the heahng of the wound, but to the ultimate effects of the procedure upon the disorder of the patient.
When conducting our experiment in bacteriology we must recognize that micro-organisms capable of causing the direst disaster may possibly be everywhere — in the air, on the hands, instruments, gauze, catgut, etc., which may be introduced into the wound, or upon the surface of the patient's body. The possibility of the patient's own tissues furnishing a septic organism is so remote that we may leave it out of account entirely. It is an excuse to condone rather than a reason to explain the occurrence of infection.
Our bacteriological experiment may be conducted with one of two intentions: (1) The exclusion of all organisms from the wound; (2) the destruction of all organisms reaching the wound, by a bactericide appKed to the wound surfaces.
It is not accurate to speak of these two methods as those of "aseptic" and "antiseptic" surgery; for to speak strictly there is no "aseptic" surgery. In every operation some antiseptic is used on the surgeon's hands or the
THE RITUAL OF A SURGICAL OPERATION Ul
patient's skin. The terms are accurate enough if they are held to apply only to that part of the operation which begins with the incision of the skin. After this point the use of antiseptics in a "clean" case is rarely necessary, is often undesirable, and is almost always of greater harm than benefit. It is to insult tissues and to doubt them, when it would be better to trust their very considerable powers of self-defence.
In speaking of the results of an operation a surgeon may be a prejudiced witness as to his own efforts, and a bad judge of his own merit. When we speak, for example, of "heahng by first intention," what do we mean? What is our standard? Let us take extreme examples. In the one we mean a wound which heals within a few days, leaving a thin, straight, narrow line of palest pink. Around this hue and the stitch-marks everything appears *'cold." There is no redness, no swelling, no stiffness or induration, and at the Hne itself the most accurate apposition of skin edges is seen. There is no discharge from the wound. There has been neither local nor constitutional reaction following the operation. In the other, we mean a wound which is anything but straight; the edges are jagged, they do not meet accurately at every part, they overlap here and there; the line of healing is broad and irregular, raised and red, a sticky discharge oozes from the unapposed surfaces, and a scab may he where this discharge has dried. The parts around are raised, tender, doughy, or stiff. The stitches seem to sink into the skin. You may see wounds of this kind in some chnics, and hear a complacent conunent that the wound has healed by "first intention." Such wounds are the clearest evidences either of a bad technique or of a clumsy operator, or perhaps of both. If we had a Dr.
4« ESSAYS ON SURGICAL SUBJECTS
Johnson in our profession, and he were asked his opinion of such wounds, what would he thunder in reply? We know what he said when pressed for his opinion of a young lady's verses: "Why, they are very well for a young miss's verses; that is to say, compared with excellence, nothing; but very well for the person who wrote them."
In every discussion it is necessary for the protagonists to agree as to definitions and the exact meaning to be attached to words; otherwise polemics are valueless. We must here discriminate between "perfect" and "imperfect" healing, though both may be classed as examples of heahng by "first intention." It is, moreover, not only a question of the healing of the superficial, visible wound which is our concern. With the two types of wound heahng I have described there are associated not only the varying chances of life or death but also two types of convales- cence, especially in abdominal cases. In the former the patient suffers hardly at all, indeed, as a rule, not at all, unless there have been great technical difficulties in the operation itself, such as remoteness of the parts concerned in a very stout subject.
For example may be quoted an operation for chole- Hthiasis, in a very fat woman, when the Hver hes high, and the gall-bladder is small, bound up in dense adhe- sions, fixed to the duodenum (perhaps with a fistula into it) and the back of the abdomen. The hver and costal margin may need to be held up, and the abdominal vis- cera to be dragged downwards, before the sclerosed gall- bladder or a dilated conmion duct containing a stone can be seen. I know nothing in surgery which approaches such cases in difficulty, or which requires such care, gen- tleness, patience, and skill on the part of a surgeon. I sometimes hear the operation for the removal of a Gas-
THE RITUAL OF A SURGICAL OPERATION lt9
serian ganglion or the avulsion of its sensory root spoken of as "difficult." It is work for a novice compared with that in many a gall-bladder case. Apart from cases such as these, which require firm handhng, the amount of reac- tion is negligible. More than half the abdominal cases, except for a little flatulence, hardly realize that they have had an operation performed. Flatulence is a trou- blesome complication not only of abdominal, but of other operations also. Its cause is uncertain. My own view is that it chiefly results from the starvation and purgation which are almost universally considered a necessary part of the ritual of deliberate operations. Both are certainly undesirable, and are possibly harmful. Sohd food is much like liquid food by the time it gets well on its way in the jejunum. As much fluid as the patient wishes to have should be allowed to within an hour or two of the time arranged for any operation, and as soon as possible afterwards. Operations on the stomach are no exception. An enema generally clears the colon quite as much as is necessary. Aperients increase the number and the viru- lence of the intestinal micro-organisms, and are apt to deprive the patient of large amounts of fluid and to cause exhaustion : efi'ects which are all most undesirable.
With the latter kind of wound just described there is a far greater general reaction and a higher degree of discom- fort or of pain, and there is a greater likelihood of compli- cations, grave or trivial, such as phlebitis, thrombosis, the late discharge of buried ligatures or sutures, or the recuTr rence of the condition which originally required operation.
Surgery should be a merciful art. The cleaner and the gentler the act of operation, the less the patient suffers, the smoother and the quicker his convalescence, the more exquisite his healed wound, and the happier his memory
v^
50 ESSAYS ON SURGICAL SUBJECTS
of the whole incident, to him probably one of the most important in his life. The results of our ritual are there- fore expressed not only in the mortahty — where the differ- ence may be slight — but also in the quality of the healing of the wound, and in the quahty of the recovery from the operation, in respect of security, rapidity, smoothness, completeness, and finahty.
In the ritual of a surgical operation the mysteries are imposed not only upon the high priest and upon the acolytes, but upon the congregation also. Every visitor to an operation theatre takes a part, however remote, in the operation. He is gowned, masked, and his head cov- ered with a cap nowadays in all cUnics. But dirty boots and soiled trouser legs, conveying mud, dust, and faecal matter from the streets, are often unnoticed. If the wearer of them moves about the theatre freely, or goes from one theatre to another, the organisms carried in the drying filth are scattered broadcast, as the simplest ex- periment will prove. Large canvas overalls for the boots and the lower part of the leg, tying just below the knee, as a sort of legging, will afford ample and secure covering to this possible source of infection.
The surgeon and his assistants (the fewer the better) should, of course, change all their external garments before operation. The trousers and coats we all wear are very dirty. What would a pair of tennis flannels look Uke at the end of a week's wear in London .^^ Our everyday darker garments do not show the same marks, but they carry the same dirt. White sterilized trousers, clean white shoes or overshoes, sterile coat, cap and mask, all are necessary for the perfect outfit. They are much more comfortable to wear in a theatre adequately warmed, and there is a feeling of much greater freshness, both before and
THE RITUAL OF A SURGICAL OPERATION 51
after an operation, when garments are changed. But I am, no doubt, hke Jonah preaching to a converted Nineveh. All these matters are now a part of our daily routine.
The method of the preparation of our hands and arms is important. It is still a common thing to see hands washed in a basin of still water. The moment the hands are soaped and rinsed the water is polluted by the dirt washed off the skin. If the washing is continued it is obvious that the hands are being constantly re-infected from the contaminated water. If the water is emptied away, and fresh poured in, the basin, being polluted by the water it formerly contained, defiles the fresh water. And it is really not uncommon to see a piece of soap used to lather the hands, laid down, and picked up again, regardless of the fact that each contact of the soap with something else is a possible method of soihng it. The best of all plans is to wash under running sterile water. Some years ago I had water-tanks made, to hold five or six gallons, fitted with a dispensary tap, and placed over gas-coils, so that the water contained in them might be boiled. When the water boils the tap is tm-ned, and about a gallon of water allowed to run through to sterihze the tap, on the end of which a boiled plug is fitted until the time comes for use. In a hospital installation it is easy to arrange for the tanks to be sterihzed by steam and to be cooled by water running through a coiled pipe in the tank. Water can be boiled for a quarter of an hour, and cooled sufficiently for use in five minutes. Over the tank is placed a tap for refilling.
Almost all commercial soaps are sterile. The outer surface, of course, may be polluted, but when this is washed or scraped away the exposed fresh surface of the soap is sterile. Two methods of using soap are simple and satis-
52 ESSAYS ON SURGICAL SUBJECTS
factory: to use a tablet of any household soap which has been lying in a solution of acrosyl for half an hour; or to steriUze some green soft soap in a flat dish in the autoclave, and to rub oflP, time after time, with a sterile gauze swab, enough of the soap to form a good lather. After washing for not less than fifteen minutes the hands should be gently rubbed with gauze wet in spirit and biniodide solution, or in a solution of acrosyl, which is the antiseptic least likely to damage the skin. There is a great difference in the facility with which a hand can be cleaned; some rough, chapped hands, coarsened by anti- septics, clean with great difficulty; smooth hands, well cared for, are sterile very soon. A surgeon's hand should be always carefully tended; nails should be kept clean and short and smooth, and the skin like satin. Once a week or so a visit to a manicurist is desirable.
Gloves are almost universally worn during operations. I know only three surgeons the world over who are in the first rank who do not constantly wear gloves during opera- tions. The arguments in favour of their use are un- answerable. A glove properly prepared is sterile, and remains so if put on the hand without its outer side being touched by any except the glove of the other hand or a piece of sterile gauze. With practice it is rare to puncture a glove except in bone operations, and for these it is often an advantage to wear thin cotton gloves over the rubber. If a puncture does occur, a finger stall may be put on, or the glove changed in a few seconds. The bare hand is difficult to sterilize in some cases; it is almost im- possible to keep it sterile throughout an operation, as the silk- thread experiment of Kocher shows; if it is infected during an operation it can certainly not be used uncovered again with safety during that operation.
THE RITUAL OF A SURGICAL OPERATION 53
A surgeon may say that he uses gloves only for septic cases. Does he always know when an operation, or any stage in it, is to be septic? If he inadvertently soils his hand when a septic area is unexpectedly discovered, does he then put on gloves? Has he them always ready to wear? Or does he use an antiseptic in the hope of com- bating the infection which he spreads with every touch? Is it not the simpler, safer, more certain way to wear gloves which are certainly sterile, and to change them when there is any doubt as to their defilement?
But about the wearing of gloves a good deal may be said. Often they are a mere fetish. How often are gloves put on without their outer surfaces being touched or stroked by a bare hand? How often are they consid- ered rather a protection for the surgeon than for the patient? I have seen gloves put on carefully, and the gloved hand then used to palpate an abdomen imperfectly smeared with iodine. I have seen a blanket which covered a patient's legs pulled up towards his body by a gloved hand which a few minutes later was inside the patient's abdominal cavity; and I have seen cleaned hands gloved and unclean forearms left bare on more than one occasion. I have seen gloves used in the earher stages of operation, and removed when a difficulty arose in, say, an operation upon an enlarged thyroid gland, or an operation for hernia. This is a technical sin of the gravest kind. Gloves may be sterilized by boihng, or be placed in the autoclave with the dressings and sVabs and used dry. The advantage of the dry glove is that it is more comfortable to wear during a long fist of operations, and that the hand being covered by a dry sterile powder is kept free from moisture. A chance puncture of the glove does not involve the escape of a possibly contaminated fluid into the wound. Gloves
54 ESSAYS ON SURGICAL SUBJECTS
should be kept on the hands till the dressing of the wound is complete, and until the coat and sleeves are removed. If gloves are properly sterlized and properly put on, the covered finger may be used to explore a knee-joint or anywhere else with impunity.
The "knife-and-fork" method of operating, in which only instruments are handled for every purpose, including the tying of Hgatures, is a confession that the gloves cannot be trusted by the operator. If the bare hand is used during operations there is a risk which approaches certainty that the wound will be cont£iminated. This contamination may be lessened in its meJignancy by the immediate application of antiseptics, or by the free and frequent washing of the hands in a bactericidal solution; but the results either of mild contamination or of the irritation of antiseptics in the wound are expressed in those quadities of its healing to which I have referred. Many years ago, before I began to use "tetra" cloths to cover the skin around the wound up to its edges, we found that when cultures were taken from a wound they became progres- sively more numerous the longer the incision remained open; but many an infected wound healed by what we were then content to call ' 'first intention. ' ' We soon learnt that there was a degree of "clinical steriHty" of a wound which was far removed from the "absolute steriHty" which it should be our endeavour always to secure, and which alone allows of "perfect" flawless heahng and a convales- cence free from suffering. Above the gloves worn by all those directly engaged in the operation no bare arm should be seen. Either a long-sleeved gown should be worn, or sleeves which fit firmly round the wrist, there to be covered by the cuff of the glove.
Among the more important questions involved in the
THE RITUAL OF A SURGICAL OPERATION 55
ritual of a surgical operation is that concerned with the preparation of the skin. The skin does not always, indeed does not often, harbour organisms, either on the surface or in the depths of sweat or sebaceous glands, of any- special septic mahgnancy; but one can never be certain to what contact the skin has been subject, and therefore it is always uncertain whether septic organisms or spore- bearing bacilli are present or not. It is always necessary so to prepare the skin for a w ide area around the wound to be inflicted that, so far as is humanly possible, no con- tamination of the wound shall be caused from this source. Infection may be conveyed to the skin of the surgeon's hands by the examination of discharging wounds, by rectal or vaginal or buccal examinations, or during an operation. This possibiUty should be prevented by the avoidance of any contact with patients, in these circum- stances, unless gloves are worn. The principle of "ab- stinence" is the safest: the surgeon abstains from soiling his hands by contact with any potentially infective agent. ^ It is exceedingly difficult so to sterilize the human skin that it wiU long remain sterile, as all the experiments conducted in recent years have shown. When a germi- cidal solution is applied to the skin, there is a "clean fight," so to speeds., between the solution and the germs lying in or on the skin. The value of the solution as a germicide is therefore easy to test, and results obtained by these experiments may be accepted as of great value. It is far otherwise when a germicidal solution is apphed to a wound, especially to an open wound a few days old, wherein reparative processes have begun. In such a wound an innumerable number of side contests are introduced; it is no longer a fight between a germ and a germicide. There are the cellular and the fluid contents
56 ESSAYS ON SURGICAL SUBJECTS
of the wound discharge, and the various actions and reactions produced among them, the wound surfaces, the dressings, and the germicide all to be taken into account. It is a matter of interest to consider whether we do not go far astray when we assess the value of a germicide in an experiment in vitro, and then expect an equivalent germi- cidal action to be produced in an open wound. It is, I think, very doubtful whether the "antiseptic" action produced by the addition of a particular chemical sub- stance to a wound is due to those properties which it possesses as a bactericide. It probably possesses other properties also which are not strictly related to its germi- cidal power. But in the case of the skin no such perplex- ing problems arise. The efficacy of any germicide can be tested quite easily ; and the results of experiments should here guide our practice. A surgeon may say that he is satisfied with the healing of his wounds when he might quite easily have better results by using better methods of skin sterihzation. By cUnical experience, which is tedious and lengthy, we may at last realize the value of skin disinfection, which we might have determined at once by experiment. By experience we find a short way by a long wandering.
What are the requirements for an ideal skin disin- fectant? It should be cheap and easily accessible, simple in its appHcation, non-irritant, capable of penetrating the skin to some depth; it should be effective in destroying in a short time all of the organisms which are found on or in the skin, and it should do nothing to prevent or delay the clean and speedy healing of the wound.
The skin disinfectant most commonly employed is iodine. It is applied in varying strengths, and in different vehicles — spirit, chloroform, acetone, benzine, etc. The
THE RITUAL OF A SURGICAL OPERATION 57
tincture of iodine is the form which is most often used. Both experimentally and clinically the method is clearly of the second rate. The work of Tinker and Prince, Hunter Robb, Stanton, and others, shows that even when the iodine is allowed to remain on the skin which is tested, sterilization is not always indicated by the culture tube; if the iodine is removed by a solution of potassium iodide, and the skin washed with sterile water and examined, infection is demonstrable in over 50 per cent, of cases. A very large proportion of the iodine used often disappears from the skin before the operation is completed. There is notliing then to reconomend iodine but the ease and rapidity with which it can be appUed and its colouring of the skin ; its efficacy is far less than is required, and it is a powerful irritant. Iodine, to be effective, must be apphed on a dry skin, which often means a dirty skin. I have more than once seen a smear of iodine apphed over grime and filth that could not be sterihzed by a dozen similar appHcations. I have used iodine myself on a great many occasions, and have given it a fair trial; I have seen it in a very large number of clinics; yet I have very rarely seen a wound heal with all those attributes which are necessary before one is entitled to say that it is "perfect" when iodine alone has been apphed. Picric acid in alcohohc solution of a 3 per cent, or 5 per cent, strength gives better results than iodine; but it does not penetrate deeply, and it is not of sufficient bactericidal value. The wounds are, again, not up to the highest standard in a large number of cases.
Brilhant green is perhaps the most effective of all the aniline group of antiseptics when applied to the skin.
By far the best method of preparing the skin that I have ever used — and I have tried and tested many — is carried out in three stages: (1) Abundant washing with
58 ESSAYS ON SURGICAL SUBJECTS
soap and water, preferably ether soap; (2) gentle friction with biniodide of mercury and spirit solution 1 : 500 ; (3) drying; followed by the appUcation for two to three minutes of Harrington's solution. When the towels are fixed round the operation area a further apphcation of Harrington's solution is made; and throughout all opera- tions the skin is covered with towels so that no friction of the hands against it is possible. It would be well if surgeons the world over took a Httle more pride in the wounds they inflict. The appearance of a wound is often the best index to the quahty of the work that has been done throughout the operation.
The towels, which should surround the operation area as closely as possible, are fixed to the skin by cHps. On the surface of the skin left exposed a series of tiny scratches are made by a very thin needle, at right angles to the proposed Kne of incision. These are for the purpose of indicating where the stitches are to be introduced when the wound is sutured. Unless there is a mathematical accuracy of apposition there is never perfect beauty in a wound or scar, and accuracy of apposition is difficult or impossible unless some method of this kind is adopted to seciu-e it.
In so far as the actual operation is concerned, it is, for the reasons I have given, essential to avoid contact with the skin of a patient as much as possible. The hands should not touch the skin at all, viscera should not be allowed to He upon it, and the rubbing of instruments against it must be avoided. As soon as the incision is made, cloths of several thicknesses of gauze or towelHng are fixed to the skin edges and dip well into the wound. If these "tetra" cloths he loosely on the parts around the wound, they ruffle up during the movements of the sur-
THE RITUAL OF A SURGICAL OPERATION 59
geon's hands. If powder is dusted on the under surface of them it is soon found to lie in the wound. The towels must, therefore, be held at points distant from the wound, so that they are kept stretched and fixed throughout the operation. When they are removed at the conclusion of the operation, the skin covered by them is washed over with spirit and with Harrington's solution before any stitches are inserted.
The wound is made by a firm, clean sweep of the knife. Any bunghng here makes an irregular, ugly wound. A good many of the scalpels made nowadays are peculiarly unfitted for their work. I use only two patterns: one with a deep belly, made for me by Stille of Stockholm originally, and the other Stiles' pattern, which is used for all dissections. All vessels are cHpped if possible, as in a hernia operation, before being cut, but certainly the moment they are cut. If blood leaks into a wound it stains the tissues, and makes subsequent dissection along the "white fine" very difficult.
I say that "vessels" are chpped. Most of the clips made seize not only the vessels but a mass of tissue surrounding them. When ligatures are applied, all this tissue is strangled in the Hgature, and has to be digested by leucocytes in the wound. The tips of artery clips should be narrow — almost pointed — and should seize the very smallest possible portion of tissue with the vessel. If dissection is carried on in a wound, as when glands of the neck, or of the breast in a case of carcinoma, are removed, gentle traction in one direction by the surgeon, and in the opposite by his assistant, will reveal a fluffy layer of thin areolar tissue, the "white fine" as I always call it, along which dissection can proceed very easily and quickly, and with the immediate disclosure of all the vessels which must
60 ESSAYS ON SURGICAL SUBJECTS
be seized. This involves the application of many clips, but the wound should always be kept dry and unstained by blood. Kocher was accustomed to put out twenty dozen chps for a goitre operation, and on many occasions he seemed to use most of them. It should be our ideal to complete such an operation, which in my student days was often one involving much loss of blood, without staining the towels round the wound.
Though traction is necessary in gland and goitre op- erations, it must be avoided in abdominal work. There every pull means a pain. I dislike abdominal retractors intensely. The forcible and merciless retraction of the abdominal wall throughout a long operation cannot fail to cause shock and suffering afterwards. The best retractor is the gentle light hand of a well-trained as- sistant, used mercifully when it must be used at all. But with adequate incisions, retraction is very Httle needed during the greater part of most operations.
Dissection may be carried out in two manners: by the knife or by "gauze stripping." If by the knife, the movements should be short, sharp, close together, so that if recorded on a moving drum the picture would resemble a "feather edge." And the knife must be sharp. Big, heavy, clumsy movements with a dull km'fe hurt the patient, and leave the parts less fitted to heal. Through- out the operation there must be no undue exposure of parts. In a large dissection, such as that required in re- moval of a cancer of the breast, the dissection extends from the axilla to the umbilicus, and from the opposite pectoral muscle over the latissimus dorsi. With skin flaps turned back, the bared area is very extensive. It should never be seen as a whole. As one part of the dissection is com- pleted, hot moist mackintosh cloths are placed over the
THE RITUAL OF A SURGICAL OPERATION 61
raw surface to prevent drying and chilling, and the chance of contamination. Similarly, in abdominal work, only that part of the operation field should be seen with which the operator is at the moment engaged. There is no need in the operation of gastro-enterostomy, for example, for any- thing to be outside the abdomen during the suturing of the viscera except that small part of each which is em- braced by the clamps. The patient is accustomed to keep his own viscera warm, and he should still be allowed to do so. Crile's work has shown, to my mind conclusively, the need for avoiding cooHng or drying of wound surfaces.
All the instruments used during the operation are, of course, sterilized by heat; but it is important to remember that contamination may occur during an operation, and therefore the various chps, scissors, retractors, or other instruments should be resterihzed as often as is necessary. If, for example, a pair of scissors are used to open the intestine in a case of gastro-enterostomy or colectomy, or needles to suture viscera together, they are at once dis- carded, and never used again till they have been boiled. The mucosa may be sterile in a case of gastro-enterostomy, but one can never be certain, and it is safer always to assume that any possibly infected tissue is infected.
In operations for mahgnant disease, frequent steriliza- tion of instruments is most necessary. For example, in removing a breast for carcinoma, many surgeons, of whom I am one, adopt the method suggested by Rodman and Willy Meyer, and complete the axillary dissections first. There are many advantages in so doing which need no mention now. Every instrument used in this dissection — knife, clips, scissors — may possibly be brought into contact with a cancer cell. When once used it is therefore laid aside, and not taken up again till it has been reboiled.
62 ESSAYS ON SURGICAL SUBJECTS
Cancer cells, as Ryall and others have shown, can be grafted on to the patient's own tissues and develop a new deposit of cancer. It is obvious that the graft may be conveyed to any instrument, or on the gloved hand if it is at work in the wound. In all operations I have a red handkerchief placed on the table which hes over the legs of the patient. As soon as any instrument is soiled I place it on this danger spot, and it is at once removed by the nurse to the steriHzer.
As regards the material used for ligatures and sutures which must remain within the wound, certain conditions are essential. Such material should, ideally : (1) Achieve its purpose — be sufficient to hold parts together, close a vessel, etc.; (2) disappear as soon as its work is ac- complished; (3) be free from infection; and (4) be non- irritant.
The only material which can be made to fulfil these conditions is catgut. Catgut can be steriUzed perfectly. The method of Claudius, which directs that the catgut should be soaked in a solution consisting of iodine 1 per cent, and potassium iodide 1 per cent, in water, ignores the fact that with such a proportion of iodide of potassium all the iodine is not dissolved ; much of it lies inert at the bottom of the vessel. I use a solution made in accordance with their atomic weights, iodine in a strength of 1 per cent, and iodide of potassium in a strength of 1.75 per cent. ; the whole of the iodine is then taken up, a darker and stronger solution results, and catgut soaked in this for ten days or more is almost black in colour, and so strongly permeated by iodine that it is exceedingly difficult to infect it. I have never known any surgeon use silk and not have trouble from it. Silk for Ugatures is not necessary, for catgut will securely tie any vessel. Silk for
THE RITUAL OF A SURGICAL OPERATION 63
intestinal sutures is not necessary. Certainly I have not used any for fifteen years, and I have now discarded hnen thread for all but the anastomoses after colectomy. An unabsorbable suture used to effect the junction in gastro- enterostomy is possibly a factor causing the development of a jejunal ulcer. But thick chromic catgut also will remain for years at a suture Hue in such a case. In one patient I have found a piece of chromic catgut over two inches long dangUng at the gastrojejunal opening three years and nine months after the anastomosis had been made. It is, of course, as I have before pointed out, the sero-serous suture which is the offender in such in- stances. The inner mucous suture, no matter of what material, is soon loosened and escapes.
Probably we all use more sutures than are necessary in intestinal anastomoses. In urgent cases I have more than once used a single Connell suture with perfect success. But in surgery, in order to be certain that you have done enough, it is generally prudent to do more than is neces- sary. Over and over again I put in an additional stitch here and there. I know it is not really needed, but I call it my "hypnotic" stitch; for I sleep better at night when I know it is there.
The most important person present at an operation is the patient. This is a truth not everywhere and always remembered. It is our duty to make the operation as Httle disagreeable as possible for him. To many patients it is a dreaded ordeal. Our patients today are terrified by the tradition that cUngs to the word "opera- tion," a tradition started in the days when it must indeed have been a terrible procedure, without anaesthetics other than those stupefying drugs, alcohol and tobacco, with patients strapped down or held by assistants, and all the
6U ESSAYS ON SURGICAL SUBJECTS
other horrible accessories. Today an operation can, and should, be made a very simple matter, devoid entirely of anything repellent or disheartening.
The preliminary use of scopolamine, atropine and morphine, or of omnopon is a very valuable help. One dose of T^ gr. atropine and about ^h or -^ gr. scopol- amine and i or T gr. morphine is needed, according to the patient's age, size, etc. This is given about three- quarters of an hour before operation. In a private hospital the blinds should then be drawn down, the room darkened, and the patient encouraged to sleep. No talk- ing is allowed. The nurse remains in the room, but is warned not to speak, and, of course, no friends are then permitted to see the patient. When the patient is taken to the operation theatre as quietly as possible, a towel covers the eyes and the operation room itself is dark. No conversation is allowed in the theatre, and only the anaesthetist and one nurse, or possibly two nurses, remain. Everything is kept as quiet and orderly as possible. About one-third of the patients subsequently say they have little or no recollection of going to the theatre or of taking the anaesthetic. All abdominal cases are treated by Crile's method of quinine and urea injections into the parietal peritoneum, and into the nerve-trunks running to the area in which the operation takes place. There is no doubt as to the diminution of pain thereby resulting. With shock we are not much concerned. There are very few occasions indeed when shock results from an ab- dominal operation properly conducted, when the patient is kept warm on the table by one device or another, and when the gentlest handhng, the most careful haemostasis, and adequate protection of parts have been exercised.
Every detail in every operation is of importance, and
THE RITUAL OF A SURGICAL OPERATION 65
should be conceived, practised, and tested with unweary- ing patience by the operator himself, and by him in conjunction with all his assistants. Was it riot Michael Angelo who first said that success depends upon details, but success is no detail? In surgery, at least, success may well depend upon the scrupulous, exacting, and unceasing supervision and close scrutiny of every smallest incident of procedure. In respect of surgical work there may be some truth in Blake's assertion that all excellence is in minute particulars. Surgery is nowadays no longer the work of an individual, but of a "team" in which every member plays his exact part, in which all contribute to success, and in which each may bring about disaster. The well-trained team should display that mastery which is impKed by ease in smooth and efficient action. In every phase of its work there should be not merely the casual observance of a ritual the meaning of which is lost and the deeds of which are only a faded counterfeit, but acts of full devotion to principles which have been tried and proved, acts which are the witnesses to a hving and perfect faith.
It is, of course, a platitude to say that a good surgeon is not merely one who operates well. The quahties re- quired to make our ideal surgeon are many: gifts of character, leadership, wisdom — even worldly wisdom — compassion, and the finest technical skill. In respect of the latter we remember that surgery is not only a science but an art, work demanding the highest craftsmanship, and a knowledge of all the "tricks of the tools' true play."
In all the movements of the surgeon there should be
neither haste nor waste. It matters less how quickly an
operation is done than how accurately it is done. Speed
should result from the method and the practised faciHty
of the operator, and should not be his first and formal 5
66 ESSAYS ON SURGICAL SUBJECTS
intention. It should be an accomplishment, not an aim. And every movement should tell, every action should achieve something. A manipulation, if it requires to be carried out, should not be half done and hesitatingly done. It should be deliberate, firm, intentional, and final. Infinite gentleness, scrupulous care, fight handfing, and purposeful, effective, quiet movements which are no more than a caress, are all necessary if an operation is to be the work of an artist, and not merely of a hewer of flesh. For every operation, even those procedures which are now quite conomonplace should be executed not in the spirit of an artisan who has a job to get through, but in the spirit of an artist who has something to interpret or create. An operation should not only bring refief or health to the patient, but should give a glow of keen defight to the artist himself, a thrill of joy and a sense of complete satisfaction to a critical spectator.
Ours has been a necessary profession ever since man's body was subject to enmity and casualty. AU who prac- tise it wiU need the gifts of which Thomas FuUer spoke — "an Eagle's eye, a Lady's hand, and a Lion's heart." Of all of us who labour honestly may it at last truthfully be said, as it was said of James IV of Scotland, "Quod vulnera scientissime tractaret" — "He was most skilful at the handfing of wounds."
THE DIAGNOSIS AND TREATMENT OF CHRONIC GASTRIC ULCER*
Around the subject of gastric ulcer a very extensive literature has accumulated. Every country, and a host of authors, have contributed to it, imtil there must be many who doubt whether anything really fresh or important remains to be said. Yet I hold a firm behef, based upon an experience the length of which I dread to contemplate, that no small part of what is written requires ruthless revision in the hght of the modern methods of inquiry conducted by the radiographer and the surgeon. The wealth of teaching in the text-books is too often imper- sonal, and represents rather a legacy flowing from one's ancestors than a fortune newly won by hard endeavour. The heritage in respect of gastric ulcer is heavy enough, but not all of the securities are worth their face value.
A gastric ulcer is, of course, an ulcer occurring in the stomach. During development the stomach is dijfferen- tained as one part of the foregut from that other part which forms the duodenum as far down as the ampulla of Vater. The foregut terminates at the point of entrance of the ducts of the Kver and pancreas ; at the end of the second month of fetal fife the pylorus marks oflP the stomach from the duodenum. When development is complete it is, as a rule, easily possible in all periods of life to distinguish the stomach from the duodenum. On palpation the pyloric muscle and valve are felt at once. Exactly in the line
* A paper read at the opening of the Session of the Harveian Society, October 23, 1919. Reprinted from the British Medical Journal, December 13, 1919.
€7
68 ESSAYS ON SURGICAL SUBJECTS
of the pylorus a thin white line is to be seen on careful examination; the line becomes clearer if in the living subject the pylorus is held forward by a finger and thumb placed one on the stomach, the other on the duodenum, and closed to meet in the pylorus. In close proximity to the "pyloric white Une" is a vein, the "pyloric vein," which begins at or near the middle of the anterior surface of the pylorus and runs downwards to the greater curvature. The "pyloric vein" is constant, its arrangement variable. It may be single and large, short and branched, or long with only very slender branches; it may be double; it may or may not be met by a smaller vein running up towards the lesser curvature; it may Ue on either side of the pyloric white line. The perfectly fair criticism has been made against the accept- ance of this vein as a landmark, that veins are very irregular in their arrangement, position, and distribution, and that nowhere else in the body is the position of a vein so constant as this is asserted to be. And it must be frankly admitted that there is a very small number of cases in which the venous arrangment is such that no accurate localization of the pylorus is possible from a surface inspection. But there is no landmark in the body that is invariable. For many years past I have drawn the position of this vein as seen during an operation while the parts were under inspection, and it is quite safe to say that in at least 90 per cent, of the cases the markings I have mentioned may be accepted as accurate. Latarjet {Lyon Chirurgicaly 1911, vi, 337), after a research con- ducted for the purpose of deciding the value of the vein as an accurate landmark, concludes in favour of its acceptance.
An ulcer occurring on the proximal side of this vein is a
CHRONIC GASTRIC ULCER 69
"gastric ulcer"; an ulcer occurring i or | inch or more beyond it is a ' 'duodenal ulcer. " It is not merely a matter of academic interest to distinguish them; their symptoms are sufficiently distinct to allow an accurate diagnosis of duodenal ulcer to be made with remarkable constancy; their comphcations and sec[uels in respect of perforation and haemorrhage are very different; cancer develops often upon the base of a gastric ulcer, and almost never upon the base of an ulcer in the duodenum. Gastric ulcer is a disease of comparative rarity; its diagnosis from the clinical evidence alone is difficult; its mimicry by other conditions extremely frequent. These statements may not ffiid a ready acceptance everywhere. For if the text- books of medicine, or the special works of distinguished authors are read, or if the diagnosis made in the out- patient medical clinics are reviewed, it will be found that there is a general agreement that gastric ulceration occurs frequently, and that its symptoms are of a kind hardly admitting of doubt or difficulty in diagnosis. I have spent a great deal of time in reading almost everything to which I could obtain access that has been written about gastric ulcer, and I am compelled to say that when the statements univeraslly made are tested by the ex- perience gained in the operation theatre they are found to be inaccurate. My contention is that a full, clear, and truthful description of the symptoms of gastric ulcer is rarely given, and that the conditions described as "gastric ulcer" are in the majority of cases indicative of other diseases.
What are the symptoms of gastric ulcer, and how may the diagnosis be made?
Ulcer of the stomach occurs twice as often in men as in women; its chief symptom is pain. All the attributes of
70 ESSAYS ON SURGICAL SUBJECTS
this symptom merit and must receive the closest scrutiny. The chief attribute is, I think, regularity. In all cases of gastric ulcer there are periods of intermission, longer or shorter, at one period of the year or another; but when the attacks are present the pain which is then the chief feature always displays regularity. It comes after all meals, even hght meals; it is not present after breakfast on one day, after dinner on another, and absent entirely on another day. If a meal is eaten, pain during the attack follows invariably. The interval between the taking of the meal and the onset of pain is fairly constant. As a rule the earher the pain is felt after a meal, the nearer is the ulcer to the oesophagus. That is to say, if pain comes, regularly, one or one hour and a half after a meal, the ulcer that causes it is in the stomach, it is a "pre- pyloric" ulcer. If pain comes two, three, or four hours after a meal the ulcer hes generally beyond the pylorus. This period of rehef from pain after a meal is constant and invariable, both in gastric and duodenal ulcers, until stenosis, subacute perforation, or the formation of crip- pling and embarassing adhesions takes place. These con- ditions may lead to a delay in the time of the appearance of the pain in cases of gastric ulcer, or to the hurried appearance of the pain in cases of duodenal ulcer.
In over three cases in five of gastric ulcer, seen during operation, the pain came within one and a half hours of the taking of food; in rather more than four cases in five of duodenal ulcer the pain appeared two hours or more after food. The pain in cases of gastric ulcer very often disappears after an hour, or even less, and may be com- pletely reheved, indeed, it generally is, before the next meal is due. The pain of duodenal ulcer, on the other hand, appearing later, generally persists, often with a
CHRONIC GASTRIC ULCER 7i
slowly increasing severity, until the meal is taken. The character of the meal influences the pain. A generous meal of heavy foods causes severe pain to appear at an earher time in gastric ulcer; it delays the appearance of the pain in cases of duodenal ulcer. Smaller meals of soft, pultaceous food, easy of digestion and easily pro- pelled, produce less pain, and the interval of relief brought by the food is longer. An indiscreet and hasty meal, espe- cially of fruits, or salads, or pastry, may give instant and grievous pain. A bland and blameless diet taken in small quantities at brief intervals may reduce the chances of pain appearing, or even afford complete relief. In a small proportion of cases pain may not be influenced by food in the manner and to the extent now described. When the ulcer is near the cardia there may be no rehef from taking food, or pain may inamediately be made worse; each of these features is present in approximately 4 per cent, of the cases.
The pain is variously described: it is a deep, * 'boring,'* "burning," or "aching" pain; there may be "gnawing" or a sense of acidity and a desire for food or warmth. The pain in a majority of cases is said to be on the left side or high in the epigastrium; in some severe types there may be great complaint of pain in the back. In twenty-three cases in which there was a deep excavation in the pan- creas consecutive to a subacute perforation of the ulcer on the lesser curvature or posterior wall of the stomach, seventeen patients complained bitterly of the intolerable aching in the back. As we know, many patients attacked with acute pancreatitis suffer most from pain in the back, and it is an old observation and an accurate one that a deep eroding ulcer of the pancreas may also produce this most distressing symptom.
n ESSAYS ON SURGICAL SUBJECTS
The position of the ulcer, its freedom from adhesion to neighbom'ing parts, and its size, all seem to affect the type of pain, its periods of latency, and its time of onset after meals. When ulcers are small and seated high up on the lesser curvature, or just on the posterior surface, the symptoms are shorter in duration, but more prone to recurrence. They are often, as we learn from the radio- graphic examination, attended by severe forms of local spasm, which are responsible for the sensations of dis- tension, weight, and pressure, which appear to accompany these ulcers more often than those of other types. If the ulcer is large, excavating the hver, or burrowing deeply into the pancreas, or if it is fixed by firm broad adhesions to the abdominal wall or the Hver, the symptoms are less likely to show those intermissions which are so charac- teristic of the earlier stages. If, therefore, in the history of an individual case we learn that the periods of freedom from suffering have become by degrees shorter, and have finally vanished, we may often predict that some of the conditions named are present. If, in addition, there are wasting and especially anaemia, we may be very suspicious of the onset of malignant disease.
Rehef from pain is obtained not only from food, but from alkalies, sodium carbonate, "mint drops," or from vomiting. Lavage of the stomach often gives great temporary relief.
The fact that the severity of the pain is so often mitigated by food accounts for the fact that many patients do not lose weight, or may actually gain weight during an attack. Patients with gastric ulcer recognize that heavy meals three times a day bring their own punishment. Lighter meals are taken at shorter intervals, and the total amount of food, much of it of high value,
CHRONIC GASTRIC ULCER 73
is accordingly far greater than that usually consiuned. Weight is therefore gained.
About one-fifth of the patients who are found to have gastric ulcers complain not only of pain, but of great prostration, feebleness, or lassitude coming on just at the time when the pain is due. On close enquiry this most distressing symptom may be found to have preceded the experience of pain by weeks or months. The periodicity of the two is identical.
It is not possible to emphasize unduly the importance of ascertaining all these various modifications of the one symptom, pain. The constancy of the sequence — food, comfort, pain ; food, comfort, pain — ^is the most important of all the chnical matters concerned with the diagnosis of gastric ulcer.
The next symptom in point of frequency is vomiting. In all forms of ulceration of the stomach or duodenum vomiting is an inconspicuous feature, unless obstruction has developed as the result of the cicatrization of the ulcer. Indeed, a degree of obstruction which is by no means trivial may be present, and yet vomiting is very infrequent or entirely absent. It is no uncommon experi- ence to hear a patient say, 'T never vomit," and for an operation to disclose an extensive ulcer or a moderate degree of stenosis in the body or near the pyloric orifice of the stomach. Patients seem to have a great capacity for estimating the degree of tolerance possessed by the stomach, and of taking only such foods, or foods in such measure, as will arouse no resentment. In the earfier stages of the development of their malady vomiting is not seldom self-induced in order to ease the stomach of a heavy load, and a sense of pressure and distension. But a very little experience seems to teach the greater number of
74 ESSAYS ON SURGICAL SUBJECTS
patients the quantity of food that is appropriate for them. Thereafter vomiting occurs quite infrequently. It has probably been present on a few occasions in more than half the number of patients who have suffered in many attacks, but it is rare to find that quick reference is made to it when the history is being disclosed.
When in the record of any patient suffering from "dyspepsia" there is a story of frequent vomiting, of the inabihty of the stomach to tolerate the presence of any foods, of even fluid nourishment sparsely taken being at once rejected, the thought that gastric ulcer is the cause should be driven from one's mind. That type of history, which is conmionly heard, is, I find, rarely present in cases of organic disease of the stomach. The vomiting due to the presence of an ulcer is infrequent, and occurs almost always not immediately after food, but after a shorter or longer interval. The meal at first causes rehef, and only after that period of relief does it cause disturbance.
Hxmatemesis also occurs far less conmionly than is supposed. Haemorrhage manifest as melaena, or in the vomit, is recorded in less than 25 per cent, of my cases; in the majority of these the amount of blood lost was trivial, and of many in which "haematemesis" is recorded it is at least doubtful whether blood was, in truth, present I think it is true to say that when blood is discharged from the stomach either in a fresh state or as "black vomit," it is conunonly believed that a chronic ulcer is present. There is a great fallacy in such opinions. That gastric haemorrhage occurs, and occurs profusely, in ulceration both of the stomach and duodenum is certain; but the number of other conditions that give rise to haemorrhage is so large that the possibihty of a gastric ulcer being the source of the blood should not be strongly, or ex-
CHRONIC GASTRIC ULCER 75
clusively, held. I have so often seen haemorrhage of the most abundant kind ascribed to "gastric ulcer" which was caused by such other conditions as splenic anaemia, cirrhosis of the liver, appendicitis, and other infective conditions within the abdomen, that in the elucidation of the cause of such a condition as profuse haematemesis I seem to turn to other possibihties than gastric ulcer in the first instance. It is true that there may be a confusion as to terms here. For when a patient dies of such haemorrhage a very close examination of the gastric mucosa may reveal the existence of tiny chaps, or cracks, or fissures from which blood has certainly issued. And when in the old days of unwisdom we operated upon such patients and explored the cavity of the stomach the mucous membrane was said to "weep blood," Httle trickles of blood could be seen to issue from many points. But these little gaps in the mucosa are not ulcers of the kind that produce clinical symptoms. If a patient has suffered for months or years from dyspepsia, and then is seized with an acute attack of vomiting and haematemesis, and if an operation urgently performed reveals the condition of the mucosa I have just described, it is the worst of fallacies to connect the dyspepsia with the "ulcer" or ulcers then supposed to be present in the stomach. The ulcer which has caused repeated attacks of in- digestion is always a gross lesion, a lesion in which there are present not only the evidences of destruction, but also of defence; around the crater of the ulcer is an area, greater or less, of inflammatory action, and the serous coat of the stomach is plainly involved. If the breaches of continuity which permit the escape of blood in cases of cirrhosis of the Hver, splenic anaemia, and the toxic conditions which, as a rule, have their origin within
76 ESSAYS ON SURGICAL SUBJECTS
the abdomen, are called "acute ulcers," as they often are, it is essential to remember that such ulcers are recognizable by no other clinical evidence than haemorrhage, or in exceedingly rare instances by perforation; they are never the cause of a continuing or recent dyspepsia. The re- lation between acute ulcers and the chronic ulcer which is so disabling is not certain. Dr. Bolton, whose work on Ulcer of the Stomach is the best of all books on its subject, beKeves that one is a sequence of the other. He is prob- ably right. Yet the acute ulcer as such gives no other clinical indication of its existence than haemorrhage or per- foration. The diagnosis of "gastric ulcer'* in these cases of grave haemorrhage was held to be confirmed by the after-history and the results of medical treatment. The patients regained health rapidly, soon lost their anaemia, and were able to take food without restraint. But every- one who has considered the history of cases in which there has been a copious haemorrhage from the stomach will agree that this rebound to full and vigourous health is quite conmaon. It is so even in cases in which at a later opera- tion a frank gastric ulcer is seen.
Such, briefly stated, are the symptoms of gastric ulcer. As will be realized, the chief dependence in making a diagnosis is placed upon the one symptom — pain. What are the other methods of investigation which can help us to a decision? Chief among them I now place the examination of the stomach after a barium or bismuth meal by x-rays. In this work I have rehed upon my colleague, Mr. Scargill, and I am greatly indebted to him for his most careful and accurate work and for the skill which he shows in the technical sides of it. His methods, which follow closely upon those of R. D. Carman of the Mayo Clinic, show that the possibility of making an
CHRONIC GASTRIC ULCER 77
accurate diagnosis of gastric ulcer is greatly increased by the x-ray examination; that, indeed, the radiographic examination alone is more accurate than all other meth- ods combined, and that a diagnosis which is proved by subsequent operations to be correct in indicating the presence of the ulcer or in demonstrating its size and position can be made in about 90 per cent, of cases.
The following is his method of examination: After a few hours of fasting, when the stomach is presumed to be empty, a bismuth or barimn meal of thin consistency is given, and six hours later the first examination is made. By this time a normal stomach is able to empty itself of the small amount of opaque food administered. If a residue is seen, there is a delay indicating defective action. A second similar meal is now given and the stomach examined forthwith. The radiographic signs of gastric ulcer are*:
I. Direct — The ulcer cavity itself is demonstrated. If an ulcer has penetrated into the walls of the stomach, or eroded the fiver or the pancreas, or perforated subacutely and become adherent to the abdominal waU, the crater of the ulcer can be seen fiUed with the opaque substance of a meal. If the ulcer is near the lesser curvature, it is visible in either an antero-posterior or semilateral view. If the ulcer is on the posterior smf ace the best view is obtained when the stomach is emptying. An ulcer on the anterior or posterior surface of the stomach close to the pylorus is more difficult to demonstrate.
II. Indirect. — In the majority of cases of gastric ulcer a very remarkable and sustained contraction of the circular muscular fibres of the stomach occurs in or near the segment on which the ulcer Hes. An inden-
* For full details the work of Dr. Carman should be consulted.
78 ESSAYS ON SURGICAL SUBJECTS
tation of the greater curvature, of varying degree and extent, but often so considerable as to appear almost to bisect the stomach, is most clearly seen. Its appearance, whether on the screen or on a photographic plate, is re- markable. The spasm, in the majority of cases, remains stationary during the examination; it is unaltered by palpation, massage, or by the administration of large quantities of belladonna. It relaxes under a general anaesthetic, and is not seen on the operation table, the stomach wall being then quite soft and flaccid. A similar "incisura" is present as the result of extrinsic causes — causes lying, perhaps, remote from the stomach. The commonest excitants are duodenal ulcer, infection of the gall-bladder, with or without stones, and chronic appen- dicitis. The spasm due to these causes is variable in posi- tion and duration, is modified by massage or pressure, and relaxes almost always after the administration of atropin given in an amount which produces a physiological re- sponse. It is also inconstant, present on one occasion, absent on another, and changes capriciously.
The presence of the persistent spasm is strong pre- sumptive evidence of the existence of an ulcer; the presence of an "incisura" on the greater curvature, with a *'bud-like" opaque projection on the lesser curvature, is an unequivocal evidence; in every such case an ulcer is present.
The radiographic method is the one certain method of diagnosis, and is now an indispensable addition to the older and far less accurate procedures.
Of the chemical examination of the stomach contents I do not speak with any enthusiasm. For several years my patients were submitted to this form of investigation, but I cannot think that the evidence thereby obtained
Fig. 1. — Very small "niche" type of ulcer on lesser curvature. Involves stomach wall only. No incisura seen in this case. Wire marks costal margin.
Fig. 2. — IJker crater on lesser curvature penetrating into lesser omentum. V\ ell- marked incisura on the greater curvature, almost bisecting the stomach.
Fig. 3. — ^Ulcer crater on lesser curvature penetrating lesser omentum and ad- herent to left lobe of liver. Well-marked incisura.
Fig. 4. — ^Ulcer crater on lesser curvature. Incisura in this case is a little above the level of the ulcer.
Fig. 5. — Ulcer crater on posterior surface near lesser curvature, only seen when stomach was almost empty. At operation foimd adherent to pancreas.
Fig. 6. — Hugo ulcer cavity on lesser curvature penetrating left lobe of liver. The cavity was nearly 85 inches long.
Fig. 7. — Groove-like ulcer on the lesser curvature 1^ inches long. Very well- market! spasmodic hour-glass contraction. No hour-glass at operation.
Fig. 8. — Ulcer crater on lesser curvature with w ell-marked incisure. (Dr. G. W.
Watson's case.)
CHRONIC GASTRIC ULCER 79
enabled a greater accuracy to attach to the diagnosis or justified the increased trouble it gave to them. Hyper- chlorhydria is present in so many other diseases than gastric or duodenal ulcer that its presence does not offer positive or even contributory evidence of any real value. In rather over 40 per cent, of the total number of cases in which an ulcer is present there is no hyperchlorhydria, and in a small number, estimated at from 10 to 20 per cent., there is a reduction in the gastric acidity. For reasons connected with the war I have rarely submitted patients to this form of inquiry in the last four years, but it will be interesting to discover the relationship, if any, between the degree of gastric acidity and the quality and duration of the gastric spasm due to extrinsic as well as intrinsic causes.
Physical examination, in the absence of obstruction in the body, or at the outlet of the stomach, reveals very little. There is a record of tenderness in the epigastrium in almost every one of the patients who are subsequently found to have an ulcer in the stomach. In ulcers of the lesser curvature I have sometimes found great tenderness high up on the left along the costal margin — tenderness which becomes more acute when the patient breathes deeply. The kind of sensitiveness is then present on the left side which on the right estabhshes "Murphy's sign." The signs in pyloric obstruction and in hour-glass stomach are, of course, well known.
If all the methods of examination are strictly brought to bear upon the cases commonly referred to as those of "gastric ulcer" it will be found that in a majority the diagnosis cannot be upheld. The diagnosis of gastric ulcer is loosely and inaccurately made; a host of other diseases, functional and organic ahke, are so described,
80 ESSAYS ON SURGICAL SUBJECTS
and in consequence the belief is widely held that "gastric ulcer" is a conunon disease. It would be more accurate to call it a rare disease. Over a series of years I find that for every gastric ulcer seen on the operation table, there are four or five duodenal ulcers, and five to six cases of cholehthiasis. A gastric ulcer is by no means easy to recognize even after the most scrupulous inquiry and ex- amination. More mistakes are made in the diagnosis of gastric ulcer than is the case in any other abdominal disorder.
It must now be generally recognized that many of the diseases arising in connexion with the abdominal viscera are, for months or years, looked upon as cases of gastric disorder. I pointed this out a few years ago in two papers published in the British Medical Journal (October 18th, 1907, "Pathology of the Hving," and November 28th, 1908, "Inaugural Symptoms"). Up to the time of the pubHcation of these articles it had not been recognized that in cholehthiasis, for example, all the prodromal symp- toms were attributed to defects in the stomach, and the medicaments administered were in consequence those used in gastric diseases. The same statement holds good with regard to chronic disease in the appendix, in the small or in the large intestine. We are now feimihar, as the result of x-ray examination and of the chemical exami- nation of the gastric contents, with the truth that all these conditions express themselves in terms of gastric disturb- ance, of hypersecretion, and of spasm. And at the time when operations are performed we can discover by inspection of the stomach such conditions as enable one to predict that a lesion will be found on closer manual examination not in the stomach, but in the appendix or its neighbourhood.
CHRONIC GASTRIC ULCER 8i
If, for example, a patient has had a type of dyspepsia which has led to a diagnosis of gastric ulcer and an opera- tion is performed, the stomach may show no scar, nor can any examination, however careful, display the ulcer whose presence was predicted. If, however, the stomach is closely inspected before it is handled the following con- ditions may be seen: The pyloric part of the stomach is decidedly redder than natural — there is a "pyloric blush." That part of the stomach is soon observed to contract eagerly and vigorously ; sometimes the spasm is so severe and so prolonged that there may be a suspicion of a tu- mour, but by degrees the spasm relaxes, and the parts be- come supple again. The spasm may be irregular, now at one part, now at another; now slow and deliberate, now fugitive. Along the greater curvature the glands are enlarged. When these three conditions are seen the prophecy may be confidently made that the stomach is healthy and that the appendix (or one of its neighbours in the alimentary canal) is diseased. In such cases gastro- enterostomy has often been performed, sometimes, it is curious to note, with benefit, but as a rule with disastrous eflfects. It has been my lot to perform a secondary opera- tion upon many such patients, and to remove a badly diseased appendix or to resect a tuberculous intestine, and perhaps to undo the anastomosis which should never have been made. The work of Cole, Barclay, Carman, and others explains quite clearly how it comes about that these intestinal disorders affect the stomach and cause its musculature to contract in the irregular and painful man- ner which raises the suspicion, or seems to make certain the opinion, that an ulcer is present. But there is also the infective element in such cases, as Wilkie has shown experimentally, and it is the toxaemia which is its outcome
6
82 ESSAYS ON SURGICAL SUBJECTS
that leads, as Spencer and Hutchinson have shown, to profuse haemorrhages from the stomach.
The stomach is an organ full of sympathy for other sufferers. Hardly any of the viscera connected with the intestine, or the bowel itself, can be affected without the stomach playing its part in the disturbance also. This ii does by pouring out an excess of secretion, and by tumultuous and irregular activities. It speaks so loudly that its voice only is heard.
The whole subject now briefly mentioned requires close and prolonged investigation. We must seek to find out as accurately as possible the chnical indication that will lead us to diagnose a veritable lesion of the stomach in certain cases, and in others to be able confidently to say that the stomach is intact, and that other organs are teUing the story of their own disease in terms of stomach discomfort.
Differential Diagnosis
The very great difficulties in the diagnosis of gastric ulcer are due to reasons which we can now fully appreciate. An ulcer of the stomach does not arouse symptoms merely because of the gap in one or more of the several layers of the stomach. We may be certain of this because, after an "attack" of gastric ulcer is over, and the patient is wholly free from symptoms, an operation may disclose the open crater of an ulcer large or small. The exact cause of the symptoms is uncertain, but, so far as we know at present, other conditions, in addition to the structural defect, must be present befOTe the symptoms appear. These are:
I. Evidences of infection around the ulcer, such as induration, local peritonitis, the deposit of fat in and around the base of the ulcer, and enlargement of neigh-
CHRONIC GASTRIC ULCER 83
boirring glands. The "sentinel gland" of Lund is constant in cases of active ulceration.
II. Spasm of the musculature of the stomach. Of the presence, severity, and duration of this condition we had very little knowledge until the methods of examination by x-ray became perfected, chiefly by R. D. Carman. We now know that a high degree of spasm is present and constant in examples of ulcer bf the stomach, and present, though inconstant and variable, in those cases where there is no primary lesion in the stomach.
III. An increase in the acidity of the gastric juice. This hyperacidity is by no means constant either in gastric or in duodenal ulcer, but it is possibly a factor of importance in the awakening of symptoms.
These three conditions — infection, locahzed spasm of the gastric muscle, and hyperacidity — are all present not only in true ulcer of the stomach but also, in varying degrees, in most of those distant conditions which are able to arouse a gastric reflex; and it is their presence which causes that mimicry of the symptoms of gastric ulcer by other lesions which may be so exact as to deceive the most expert enquirer. My own strong feehng is that in order to obtain precision where so much has been vague, no diagnosis of chronic ulcer should now be confidently accepted unless the ulcer is diagnosed by aj-ray examina- tion or is displayed upon the operation table.
The diagnosis of gastric ulcer from a study of the chnical and chemical evidences alone is so uncertain; the various methods of treatment associated with the names of Lenhartz, Leube, Cohnheim, Bolton, Sippy, and others, so helpful in all cases of infection of the alimentary canal, and the physical repose which accompanies the treatment so weighty an influence for good, that no certain con-
8U ESSAYS ON SURGICAL SUBJECTS
elusions can be drawn from even a long series of cases. In order to allow of an acciu'ate judgement to be made of the value of any form of medical treatment we must be certain, in the first place, that a real gastric ulcer is present. The concurrence of the radiographer and the surgeon in the diagnosis is necessary. The mere expres- sion of an opinion, however confident, by a physician, however distinguished, in the absence of this confirma- tion, is for scientific purposes entirely without value. When the diagnosis is assiu'ed and accepted, then med- ic£j treatment may be carried out and its results exam- ined. The radiographer should follow the treatment, examining with the x-ray say once a month to discover the changes which have taken place, and in the end to assert that heahng has, or has not, taken place.
The tempor£uy^ absence of symptoms, as the surgeon knows weU enough, by no means indicates that the ulcer is healed. If it is not healed the radiographer will recog- nize the fact at once. There is urgent need of some accurate knowledge upon these matters; at present we have little or none.
How great the difficulty in diagnosis really is could not be better shown than by a study of those cases in which the patients have been given over to the care of the surgeon for treatment, and in which the operation of gastro-enterostomy has been performed without ben- efit. There was a time when this operation was held to be the certain cure for ulcer of the stomach. If its "mechanical" virtues were not urgently needed because of the obstruction caused by the ulcer, its "physiological" eflfects at least would be salutary. A fist of the diseases called "gastric ulcer" by careful medical men, often after consultation with others, and treated by operation,
CHRONIC GASTRIC ULCER 85
was considered by me in a paper in the British Medical Journal (July 12th, 1919). It is humiliating and heart- breaking to ponder over the mistakes in diagnosis which come to hght in the records which were considered during the preparation of that article. In many of these cases a diagnoses of gastric ulcer had been made on evidence that was considered adequate by careful practitioners. We cannot rid the matter of error imtil we realize how very difficult the diagnosis of gastric ulcer really is, and until we decide that, no matter how confident the clinical diagnosis may be before operation, it shall not guide us during the operation too firmly. It is many years since I decided for myself that no gastric or duodenal ulcer existed unless it could be seen, felt, and demon- strated to a sceptical onlooker. It will help to a better understanding of the whole most difficult subject if in future no diagnosis of gastric ulcer is accepted, as a basis for treatment, unless the presence of the ulcer is made certain by a;-ray examination or by operation. To accept the clinical diagnosis of gastric ulcer and to perform any operation upon the stomach without most clearly recognizing the ulcer is to court disaster. If the mistakes in diagnosis to which I have referred had been followed by medical rather than by surgical treatment, what would be the value of the experience derived from the cases in deciding upon the effect of similar treatment in veritable cases of ulcer? The truth is that we cannot state in terms of accuracy the results of medical treatment of gastric ulcer imless and until we are certain that an ulcer has been present. And, as I have said, the clinicgJ evidences alone are very fallacious.
86 ESSAYS ON SURGICAL SUBJECTS
The Treatment of Chronic Gastric Ulcer A. Medical Treatment
I hope we may now agree that the results of the treat- ment of gastric ulcer by any of the systems already mentioned, or by any dietary or medicinal regimen, are vitiated by the lack of accuracy in the diagnosis of gastric ulcer. The most popular of all methods is that introduced by Sippy, which would appear to meet more combatantly those conditions in the stomach which he beheves must be controlled before an ulcer can have the chance to heal. It is based upon the wide-spread behef (is it anything more?) that the reduction of the acid in the stomach is the first necessity. This is att£iined by dilution of food, alkaUniza- tion of the gastric contents every hour, by the adminis- tration of fats, and by lavage.
The questions which in this connexion require answer are:
1. Does a chronic gastric ulcer ever heal under
medical treatment?
2. Does it long remain healed?
3. Does it heal without producing such conditions as
need surgical treatment for their rehef ? 1. Chronic gastric ulcers probably heal sometimes under treatment, or after the exercise of continued care in diet. The scars left by their heahng are seen, though very rarely, in the post-mortem room and, still more in- frequently, in the operation theatre. The discrepancy between the reputed frequency of gastric ulcer and the scarcity of the scars found in the dead-house has not attracted adequate attention. The number of healed cicatrices found in the operation theatre, when the stom- ach is examined as a routine in almost all operations, is
CHRONIC GASTRIC ULCER 87
exceedingly small. This may be due to the rarity with which sound healing occurs, or to the tendency of healed ulcers to break out afresh. All the available evidence strongly supports the opinion that the firm heahng of a chronic gastric ulcer is a very unusual occurrence.
2. Do ulcers when healed long remain so? In the majority of cases the answer must be No. The character- istic quality in the symptoms of gastric ulcer is recurrence. There is a succession of "attacks," of changing severity and of variable length. The tendency, on the whole, is towards more serious attacks with briefer intervals. It is not by any means certain that an interval in which there is freedom from suffering means that the ulcer is healed. In hour-glass stomach, where a considerable degree of contraction has occurred in the body of the organ, it is a matter of great rarity to find that the ulcer is soundly healed.
3. When a gastric ulcer of moderate or large size heals there is inevitably some degree of contraction. In this way hour-glass stomachs are produced, and stenosis near the pylorus. We cannot say with what frequency the successful medical treatment of a chronic gastric ulcer produces the conditions which need surgical reUef, but it is certainly not seldom, for any large scar wherever placed, and especially if it has contracted adhesions to neighbouring parts, must embarrass the action of the stomach, or cause distress after food. Notwithstanding any or all of these considerations, a really serious attempt to treat all cases of chronic gastric ulcer by medical treat- ment should be made. It is best to have no half-measures. It is at least arguable that the necessity for surgical rehef in many patients is due to a too perfunctory trial of medical treatment in the earlier attacks. The hospitaj
88 ESSAYS ON SURGICAL SUBJECTS
accommodation in the country is too small to allow of the poorer classes receiving the rest and supervision that is necessary. The pressure on beds is too heavy. The ideal would be to keep the patient under treatment until an x-ray examination showed that the ulcer was healed.
B. Surgical Treatment
In discussing the surgical treatment of gastric ulcer the first matter for consideration relates to the importance of discovering any sources of still continuing infection which may first have led to the development of the ulcer. The primary infection cannot always be discovered — indeed, cannot often be locaHzed with certainty — but it is a fair assumption to make that any chronic infection of which the evidences are still discoverable may have acted as a cause of the original ulcer, or have provoked a re- currence of it in one or more of those attacks which are a characteristic feature of the cHnical history. The causal infection may not be found until the abdomen is opened, for in my view a large number of the cases of gastric ulcer upon which the surgeon must operate are secondary to an infection arising in some part of the intestinal canal, more especially in the appendix. But there are not a few cases in which the infective agent appears to reach the stomach by way of the mouth. Disease of the teeth or gimis, of the antrum or other accessory sinuses, or of the nasopharynx, have all been found in cases upon which I was asked to operate. If in any such case the lesion is a gross one, and likely long to continue, it is most necessary that it should be dealt with before any operation upon the ulcer itself is undertaken. If constant search is made for a diseased fang, alveolar abscesses, and septic conditions in the upper part of the pharynx or air passages,
CHRONIC GASTRIC ULCER 89
the evidence of serious disease, requiring radical treat- ment, will be discovered far more frequently than is generally beheved. One method of inquiry worth pur- suing is the investigation by x-ray of the alveolar proc- esses in all patients to whom a barium meal is to be given preparatory to a screen examination of the stomach. One of the factors most certainly causing a recurrence of ulceration in the stomach, or of ulceration at or near the suture line after gastro-enterostomy has been performed, is infection derived from one or other of the several sources here indicated.
The necessity for the surgical treatment of a gastric ulcer is a confession that medical treatment has failed. As conomonly employed, it is doomed to failure. It too often consists in the mere administration of a bismuth mixture when the sufferer is treated in the out-patient department of a large hospital. There is not anything approaching the necessary accommodation in hospitals in this country for the patients suffering from gastric or duodenal ulcers, whose successful treatment by medical means necessitates that constant, watchful supervision of every detail which hospital treatment alone affords. A successful operation upon a patient suffering from gastric or duodenal ulceration will depend in part upon careful and adequate preparation. Not a few of the patients are weakly, ill-nourished, and of a low resisting power when first they come under our care. By keeping them at rest for a few days, giving them large quantities of fluid by the mouth, or by rectum, or subcutaneously; by the administration in such fluid of sodium carbonate or glucose; or occasionally by performing a direct trans- fusion of blood, their condition can be greatly benefited, and the risks of operation correspondingly reduced. The
90 ESSAYS ON SURGICAL SUBJECTS
practise of withholding fluids for a few hours before operation is always, I think, a procedure of very question- able value; in patients reduced in strength by lack of nourishment, or by pain extending over long periods, it is positively a factor pregnant with harm. When the opera- tion is performed the choice in exceptional circumstances of hedonal as an anaesthetic is very helpful. The anaes- thesia is quietly induced, lasts long, gives remarkable relaixation of the abdominal wall, and provides two or three pints of fluid at a time when fluid is much needed. The surgical treatment of a chronic gastric ulcer* may call for the performance of one or other of the foUowing operations:
I. Gastxo-enterostomy, II. Excision. III. Gastxo-enterostomy combined with excision by knife or by cautery
(Balfour's operation). rV. Gastro-enterostomy combined with jejunostomy (Moynihan). V. Resection of a part of the body of the stomach — "sleeve resection." VI. Partial gastrectomy.
I. Gastro-enterostomy
The operation which has been the most frequently practised in the past, and is still that preferred by many operators, is gastro-enterostomy. The operation was first practised on September 27th, 1881, by Wolfler in Vienna. He was dealing with a case in which carcinoma of the pyloric part of the stomach was causing obstruction, and the intention was to remove the growth by one of the methods recently introduced by his master, Billroth. Owing to the presence of secondary deposits and the fixity of the tumour, resection was impossible, and the abdomen was about to be closed when Nicoladoni, acting
* Discussion of the treatment of the acute perforation of a chronic gastric ulcer is omitted from this paper.
CHRONIC GASTRIC ULCER 91
as assistant, suggested that the obstruction might be relieved by making an opening between the stomach and the small intestine. The success in this, and in many similar cases, was an event of great significance, and one of the most important landmarks in the history of ab- dominal surgery. It was not long before examples of pyloric stenosis due to the healing of a simple ulcer were treated by the same method. What happened is known to all the world. Patients who had suffered for years from the miseries of the confirmed dyspeptic, who finally had the extreme discomforts caused by the recurrent vomiting of the stagnant and fermenting contents of the stomach, who Hved on the most restricted diet in order that their sufferings might be lessened, were suddenly restored to vigourous health, were able to satisfy, without appre- hension or unhappy consequences, their keen appetites; rapidly gained health and happiness, and added con- siderably to their weight. No operation in surgery had ever produced more striking or swifter results. Owing largely to the advocacy and the successful w ork of Doyen, the operation began to be practised in cases of ulcer oc- curring in the body of the stomach, cases in which no obstruction was caused either by the open ulcer or by the stenosis resulting from its partial cicatrization.
Results by no means so happy were soon witnessed, and in cases whose number seemed quickly to mount up the ultimate consequences of the operation were disastrous. There were several reasons for this. The chief, perhaps, was the inaccuracy of the diagnosis in many instances. It was not then, it is not now, sufiiciently realized that the diagnosis of gastric ulcer is difiicult and that the disease is rare. The operation came to be practised for "chronic dyspepsia," and many of the Httle splashes of thick lymph
92 ESSAYS ON SURGICAL SUBJECTS
so often seen on the under surface of the transverse meso- colon, adherent to the posterior wall of the stomach, were assumed to be the scars of gastric ulcers which had healed. And so in many cases when the stomach was normal, where the lesion causing the symptoms lay elsewhere, the short-circuiting operation was performed, with unhappy consequences. Another reason for the disasters following upon operation was a technical one. The anastomosis was made with a long proximal loop, which, emptying with increasing diflficulty, became waterlogged; or adhesions obstructed the efferent jejunum; or the opening into the stomach was badly placed. From one or other cause such difficulties as regurgitant vomiting were frequently seen. Further reasons were found in the inabihty of the ulcer to heal even after gastro-enterostomy had been per- fectly performed in an appropriate case, and in the later development of cancer of the stomach, presumably upon the base of an unclosed ulcer.
A few years ago a revision of my own cases in which a gastric ulcer had been clearly demonstrated showed that the results could be classified into three groups.
1. The Results were Excellent — ^With the same alacrity that is witnessed in cases of duodenal ulcer, or in cases of pyloric stenosis, the patient lost edl discomforts, and made a speedy and excellent return to health. I had not then in all cases indicated in a diagram, made immediately after the operation as I do now, the exact position and the approximate size of the ulcer; and therefore I am not able . to say exactly what the condition of the stomach was in this group of cases. But in many cases it is certain that the ulcer was near the pylorus; that the gastro-enteros- tomy opening was on the proximal side of it. In others the ulcer was on the lesser curvature and was small,
CHRONIC GASTRIC ULCER 93
and free from adhesions. It had not, that is to say, perforated the coats of the stomach to become adherent to the abdominal wall, hver, or pancreas.
2. The Results were Indifferent. — Some patients were found to have improved, in many cases for periods of months or years, others were known to have relapsed. At a subsequent operation the ulcer was found to be still present; it was then removed by local excision by the cautery, or by the performance of the operation of partial gastrectomy.
3. The Results were Bad. — In this class of cases malignant disease developed in the base of the ulcer, and so near the ulcer as to make differentiation im- possible. The question of the degeneracy of a simple ulcer into a mahgnant one is still warmly debated, and there is no approach to an agreement between the several authorities. The evidence considered by the protagonists on either side is clinical and pathological.
In more than half the cases of carcinoma of the stomach treated by operation there is a history suggestive of the previous existence and of the recurrence of a gastric ulcer. No one is more ready than I am to admit that such a history is not a full warrant for asserting that an ulcer has been present. For on the clinical evidences alone a diagnosis of gastric ulcer, however confidently made, cannot always be upheld. The only certain evidence obtained before operation is afforded by a radiological examination, and I do not know of any case in which a diagnosis of gastric ulcer has been positively made with this and other methods in which carcinoma was subse- quently found. The cUnical evidences, therefore, how- ever strongly suggestive, are not positive proof. In about 25 to 30 per cent, of the cases of carcinoma of the stomach
P4 ESSAYS ON SURGICAL SUBJECTS
removed by operation the claim that the mahgnant change is imposed upon a simple one appears on patho- logical grounds to be irrefutable; and every surgeon knows that in a small number — not less, certainly, than 10 per cent. — of the cases of gastric ulcer, to all appear- ances simple in character, a microscopic examination of the specimen removed by operation reveals the early stage of carcinoma. Now, histologists do not always agree as to the conditions which may be accepted as indicating the earUest changes from simple to carcino- matous states. Much of our knowledge of the micro- scopiceJ appearances of cancer is based upon an examina- tion of specimens long dead, of specimens months or years old, which have been lying upon the laboratory or museum shelves. The changes that occur in such circumstances are not known. But, as I have ventured to urge, an examination of specimens so recently removed as to be hardly yet dead is necessary before we know what conditions in carcinoma are authentic and what are the changes which are merely due to corruption. We must recognize a "histology of the living," which is probably as far removed from the histology of the dead as we now all recognize the "pathology of the living" to be from the pathology of the dead.
We must finally consider this fact also, that when gastro-enterostomy is performed for a chronic gastric ulcer, the "physiological" results of the operation, though they may not bring about the healing of the ulcer, may yet delay or prevent its progress towards carcinoma. We must take account of the possible effects produced by the change from an acid to an alkahne medium. Nothing is more remarkable than the difference in destiny of a chronic duodenal ulcer and of a chronic gastric ulcer. It
CHRONIC GASTRIC ULCER 95
is admittedly one of the great rarities in pathology to find an ulcer of the duodenum that has become mahgnant; and it is certainly a far more frequent thing, allowing for all reservations, to find an ulcer of the stomach in which carcinoma has developed. Embryologically the stomach and the duodenum as far down as the ampulla of Vater are one. This difference in the prospective changes in ulcers on one or other side of the pylorus may be due to the different reactions of the fluids by which they are bathed. Those who practise the operation of gastro-enteros- tomy for the relief of ulcers in the body of the stomach rely upon the so-called "physiological results" of the opera- tion— that is, upon the effect produced by the constant entry into the stomach through the anastomosis of the alkaline bile and pancreatic juice. There is no doubt that these juices are found in the contents of the stomach removed by tubage in all cases after gastro-enterostomy has been performed; and it is possible that the success of the best methods of therapy in cases of gastric ulcer — that of Sippy, for example (in which, however, gastric lavage is a factor of great value)^-depends upon the very frequent administration of alkahes, which, it is claimed, neutrahze the gastric acidity, and so allow of healing in the ulcer. Much of the explanations given is conjectural, and regard is perhaps insufficiently paid to the effect of the administration of alkahes in provoking a greater output of acid in the gastric juice to overcome the alkah administered. I am very sceptical as to any sub- stantial "physiological" value possessed by the opera- tion of gastro-enterostomy. Its other effects are purely mechanical. The stomach is emptied more quickly through a gastro-enterostomy openiiig; the pyloric spasm which so often accompanies gastric ulceration is robbed
96 ESSAYS ON SURGICAL SUBJECTS
of its effects, and the persistent local spasm which causes the characteristic "incisura" may either be prevented by a division of the muscular fibres causing it or rendered ineffective by the drainage of the stomach on its proximal side.
The making of an anastomosis between the stomach and the jejunum does not prevent the subsequent devel- opment of a gastric ulcer. I have records of one case in which a gastric ulcer, well removed from the anastomosis, developed after the operation and went on to perforation; and of three others in which gastric ulceration developed after the performance of gastro-enterostomy for a duo- denal ulcer.
Sherren^ records a case of carcinoma of the stomach developing in a patient upon whom gastro-enterostomy was performed for a perforated duodenal ulcer. Coffey, a surgeon of great sagacity, in a paper on "Gastro- enterostomy Still the Operation for Chronic Gastric and Duodenal Ulcer," records^ two cases in which an ulcer in the stomach developed after gastro-enterostomy had been performed for duodenal ulcer.
In consequence of my experience I have abandoned gastro-enterostomy alone in the treatment of chronic gastric ulcer, for:
(a) The results, even when the operation was "suc- cessful," were not so satisfactory as those which now follow gastrectomy. The morbidity was greater, the re- turn to health slower, the ability to take food early and generously was wanting, a more watchful after-care was necessary.
(6) Some cases returned with the ulcer still open, and a further operation was required. In such cases the ulcer had almost always perforated all the waUs of the stomach,
CHRONIC GASTRIC ULCER 97
and adhesions had occurred to the Hver, pancreas, or abdominal wall.
(c) Some few cases retm-ned with carcinoma of the stomach after so long an interval as to make it probable that the cancerous change had occurred after the operation had been performed. Estimates of this sort are, I admit, fallacious, for the chronicity of some forms of mahgnant disease of the stomach is remarkable. I have recently been consulted, on account of a return of her symptoms, by a patient upon whom four years and seven months ago I performed gastro-enterostomy for carcinoma of the lesser curvature of the stomach, causing obstruction, when secondary deposits were present in many glands, in the falciform hgament (one of these nodules was removed for microscopical examination and confirmed the diagnosis), and the hver.
(d) There is evidence to show that gastric ulcer may develop, even after gastro-enterostomy has been per- formed, when the stomach itself was normal.
The operation of gastro-enterostomy is made as simple as possible, though it is by no means always easy. Clamps are used, and vertical appHcation of the highest ac- cessible portion of the jejunum is made to the posterior surface of the stomach along a fine which is a continua- tion downwards of the upper part of the lesser curvature. In this way the lowest portion of the stomach is drained by the new opening. Two layers of sutures are used ; both are of the finest chromic catgut (six nought). It is never necessary to have more than two layers, nor to use any unabsorbable material, such as hnen or thread or coarse chromic catgut. Any large vessel springing from the greater curvature and running directly on to the anasto- motic fine is hgatured separately. The opening into the
98 ESSAYS ON SURGICAL SUBJECTS
lesser sac is carefully closed by approximating the cut edges of the transverse mesocolon to the suture line. The principles appUcable in all operations are observed — gentle handling, absence of exposure or chiUing of any parts directly engaged in the operation, and scrupulous care at every step. The mortahty in my own hands during the last ten years is 1 per cent., and there has been no death in the last 350 cases of gastric or duodenal ulcer.
II. Excision
The operation of excision was introduced with great hopes, which, unhappily, have not been gratified. I have practised excision by several routes, and have removed ulcers of various sizes. A small ulcer on the anterior or posterior surface has been excised, and the opening left in the stomach either closed by interrupted sutiu-es of catgut or utilized to form an anastomosis with the jejunum. Wedge-shaped excision of ulcers on the lesser curvature has been carried out, sometimes with ease, oftener with difficulty, and with a resulting deformity of the stomach. Ulcers on the posterior wall, perhaps burrowing into the pancreas, have also been removed through an incision in the anterior wall of the stomach. I have been profoundly disappointed with the results. My colleague, Mr. Collin- son, in a paper read before the American Medical Asso- ciation in 1914,^ found that in thirty-nine cases of excision there were fifteen in which severe recurrence of symptoms was observed. Eleven patients were submitted to a second operation, and seven of them showed active ulceration at the site of the excision, one had developed a fresh ulcer distal to the original one, and three had extensive adhesions which crippled the action of the stomach. The operation may fail on account of technical
CHRONIC GASTRIC ULCER 99
errors. Too small an area of induration surrounding the actual crater may be removed; the hard, stiffened edges of the wound which remain, infiltrated by inflammatory products which have long been there, may not heal kindly or rapidly, and fresh ulceration may start be- fore cicatrization is complete. Of such a condition I found evidence in a case of my own, related by Mr. CoUinson in the paper to which I have referred. In other cases a deformity of the stomach may be consequent upon the removal of an ulcer, especially of one which lay upon, or near, the lesser curvature; the normal peristaltic movements wiU then be checked at the fine of scar, as a radiological examination will plainly declare. The use of unabsorbable sutm*es, especially continuous sutures, may lead to secondary ulceration. All continuous "sero- muscular" sutures probably penetrate to the mucosa in more places than one; if this occurs, the sutm'e wiU even- tuaUy ulcerate its way through to the lumen of the bowel and be discharged, or hang loose at the suture line for months or years. Finally, even with a careful technique, adhesions may form between the suture line and any viscus or the abdominal wall in contact with it, and some embarrassment of the action of the stomach will then certainly result.
For these reasons, and in spite of some very satisfactory results, I have abandoned the operation altogether in cases of gastric ulcer. The disappointments it brings are too many, and are neither easy to foresee nor certednly to be prevented.
iOO ESSAYS ON SURGICAL SUBJECTS
III. Excision, by Knife or by Cautery, Combined with Gastro-enterostomy
At an early stage in our experience of the operation of excision alone it was found that in some instances, after suture of the wound was complete, a considerable degree of distortion of the stomach resulted, the lesser curvature was much puckered, and the whole organ warped in out- line. To have left the stomach in such a condition would inevitably have meant that a further operation would soon be necessary in order to overcome mechanical difficulties. And little by little it became the practice to combine with the operation of excision that of gastro-enterostomy also. The results were certainly better than before, but the combined operations, in point of difficulty always, and often in point of time and of danger also, equalled or ex- ceeded the operation of partial gastrectomy. As the technique of this latter operation was steadily improved, it began in my own hsinds to replace other methods, and I reverted to the practice so ably advocated by Rodman, of "removal of the ulcer-bearing area."
Balfour of Rochester, with that fertihty of resource which is one of the characteristics of his fine work, re- placed the method of excision of the ulcer by that of its complete destruction by the actual cautery. Balfour's operation has among its many merits that of simphcity. If an ulcer lie upon the lesser curvature, or near it, a little nearer the cardia than the pylorus, or down upon the posterior wall, the operation of excision was apt to be difficult. The method of Balfour makes the treatment very much easier, quicker, safer, and gives results far more satisfactory. I learnt the method in Rochester, where I saw several operations performed by W. J. Mayo.
CHRONIC GASTRIC ULCER 101
In ulcers near or upon the lesser curvature there is often a covering of fat, developed probably, as in the case of an infected gall-bladder, as a protection against perforation. This fat is dissected upwards towards the lesser curvature, until the base of the ulcer is seen clearly. The crater of the ulcer is then completely destroyed by the actual cautery, which pierces the entire thickness of the wall of the stomach. The gap which remains is closed by in- terrupted sutures, in two layers, and the flap of fat turned downwards to cover the suture line like a Ud. Posterior gastro-enterostomy is then performed in the usual manner.
Of all methods of dealing with gastric ulcer, short of gastrectomy, I am convinced that this is one of the best; it destroys the ulcer more completely than does the method of excision, for the effect of the cautery extends widely beyond the seared edge of the woimd. If by chance there is an early carcinomatous change, it is probable that much of the risk of local recurrence is removed. No more tissue is sacrificed than is necessary, and the sutiu'e of the woimd offers, as a rule, no difficulty.
My own experience of this operation is smaU. At the time when I should have been inclined to make it an almost routine procedure for many cases I had been led by my unsatisfying experience of other methods to become more and more radical in the treatment of gastric ulcer, and to consider the removal of the part of the stomach as the operation of choice. There are, however, cases in which everyone wiU admit the great value of the operation : cases of ulcers difficult of access, in patients for whom, because of recent haemorrhages, or a degree of pain which has made the taking of food exceedingly difficult, the simplest operation that is sufficient to cure, or relieve the disease, is indicated.
i02 ESSAYS ON SURGICAL SUBJECTS
IV. Gastro-enterostomy Combeved with Jejunostomy
This is a method which I have advocated and practised in cases of grave difficulty. The results have been ex- cellent. There are ulcers of the stomach so large, so awkwardly placed, and so deeply penetrating the liver, or the pancreas, in patients whose general condition is so poor that any operation becomes serious. Such cases may be unsuitable for Balfour's operation, by reason of the size or remoteness of the ulcer; and for the operation of gastrectomy by reason of the extremely feeble condition of the patient, who has perhaps recently suffered from a copious haemorrhage. In aU such cases I perform gastro- enterostomy in "Y," generally by the anterior route. The intestine is cut across about 18 in. below the flexure, the distal end closed, and the side of this distal part united to the anterior wall of the stomach. As large an opening as possible is made proximal to, or in the zone of, the ulcer and extending sometimes over the fundus of the stomach. The proximal divided end of the jejunum is then anas- tomosed to the side of the distal limb a few inches below the gastro-enterostomy opening. Into this proximal part, at a point about 3 in. above the junction which has just been made with the disteJ limb, a tube is introduced and fixed by the method of Witzel. The tube passes for several inches down through the entero-anastomosis into the jejunum. It is brought out of the gJ^dominal wall through a small separate incision to the left of the umbilicus. It is through this tube that all nourish- ment is given for months, or for years, until a radiological examination shows that the ulcer is healed, or until a trial of one month, during which food is given, discloses no return of the symptoms. During this time the
CHRONIC GASTRIC ULCER 103
greatest care is taken to keep the mouth clean by friction and frequent washing. I have never had any difficulty with a patient craving for food. The sufferings endured before operation, and the rehef immediately afterwards, by their sharp contrast, make the patient disposed to do all one asks. One patient, whose stomach showed the largest ulcer I have ever seen (we described it as resembhng the mouth of a letter box through which the hand passed deeply into the Hver), took no food for two years and nine months after this operation, though I gave her permission to do so. She took food generously through the tube, and gained over 50 pounds in weight. Since removing the tube, now a few years ago, there has been no recur- rence of symptoms. Indeed, up to the present time, in no case in which this operation has been practised has the ulcer returned.
V. Resection of a Part of the Body of the Stomach — "Sleeve Resection"
This operation is, of course, reserved for those cases in which the ulcer occupies approximately the middle part of the stomach. After resection of a cyHndrical portion of the organ the cut ends are united. Advocacy of this operation appears to be restricted to a few surgeons, and consequently the number of cases performed is relatively small. I practised it on two occasions only, long ago. In both the operation promised well, but one of the patients returned after four years with an hour-glass stomach, for which a second operation was necessary. The role of the operation is necessarily a very limited one. I think I am hardly likely to perform it again. But so far as I can judge of the experience of others it has had a fair measure of success.
iO^ ESSAYS ON SURGICAL SUBJECTS
VI. Partial Gastrectomy
My early experience of the operations already men- tioned was satisfactory enough so far as immediate results were concerned; but as time passed patients began to re- turn with one degree of discomfort or another, until I was convinced that many of the methods practised were not justified by their end-results. And by degrees I was brought to realize that gastric ulcer was a far more serious disease than duodenal ulcer. It was soon found to be comparatively a rare disease, far less frequent in occur- rence than had been universally beheved, and certainly very difficult indeed to diagnose with confident assurance and constant accuracy. The diagnosis so frequently made of "gastric ulcer" in out-patient rooms and in private practice is not sustained when the parts are examined upon the operation table. Other diseases — duodenal ulcer, chronic appendicitis, choleHthiasis, tuberculous enteritis, laxity of the attachments of the colon — are all found in the absence of any palpable or visible lesion of the stomach, and explain the symptoms of which the patient has complained. A host of diseases, organic and functional alike, are called "gastric ulcer." And conse- quently much of the literature and most of the statistics dealing with the subject of "gastric ulcer" lack that foundation of truth which only an accurate diagnosis can afford.
In the cases of indisputable gastric ulcer, when the ulcer is demonstrated beyond cavil by a radiological examination or by inspection upon the operation table, a far greater seriousness attaches to the disease than to the condition of duodenal ulcer. Operations upon it are more serious, partly by reason of the extent of the opera-
CHRONIC GASTRIC ULCER 105
tions themselves, chiefly, I think, in consequence of the less robust state of the patients. Recoveries after operation are fewer whatever the nature of the opera- tion, and the rate of mortaUty of the patients in the years subsequent to operation, as Balfour has recently shown in a paper of great value and of new significance,* is, in the cases attended in the Mayo CHnic, three times as high as in patients operated upon for duodenal ulcer. This, on reflection, is not so startHng a fact as may at first appear; for many of the patients suffering from duodenal ulcer are men otherwise of robust strength and splendid health. I have operated upon international football players, golfers, lacrosse players, and many dis- tinguished athletes for duodenal ulcer. Such people are not often found among those who suffer from gastric ulcer; and, though there are exceptions, the types of stomach found in the two diseases are distinct from one another, as Hurst has shown. The local conditions found in the two diseases are different also. A duodenal ulcer is often a simple round "terraced" ulcer affecting the intestine alone; a gastric ulcer is very prone to extend and to burrow deeply into other parts — the pancreas, the liver, the abdominal wall; and the later history of the two diseases is very different. I lean to the belief that many of the cases of carcinoma of the stomach with which the surgeon can deal successfully have their origin in a chronic ulcer. That is not the universal view, but the opinion of those who hold it is weighty and well founded. Carcinoma is excessively rare in that part of the duo- denum affected by chronic ulcer. Prompted by edl these considerations, I was graduaUy brought to view gastric ulcer as a disease requiring direct and radical treatment, and that it was not safe to trust to the indirect method
i06 ESSAYS ON SURGICAL SUBJECTS
of gastro-enterostomy, which, whether its action is "physiological" or mechanical, merely produces a con- dition of things in which heahng can more easily take place.
My choice of operation now always falls upon partial gastrectomy, whenever it can with reasonable safety be performed. The risk is not great: over a period of ten years it is not more than 2.5 per cent. All things con- sidered, and account being taken of the five years suc- ceeding operation, it is probably a safer operation and is certainly more immediately satisfactory than gastro- enterostomy alone. It cannot always be practised. The condition of the patient may forbid it. The ulcer may be so large and so placed as to make removal a matter of so great technical difficulty that the inunediate hazards are unfair to the patient. But as experience grows the number of such cases diminishes. Nowadays I rarely practise any other operation than partial gastrectomy or gastro-enterostomy in "Y" combined with jejunostomy. The details of the operation of gastrectomy are briefly these: The duodenum is divided just beyond the pylorus, after ligature of the pyloric and gastro-duodenal arteries. An opening is made in the transverse mesocolon, in the arch of the anastomosis of Riolan in order to guide the surgeon in his ligature of the omentum below the greater curvature, so that the middle cohc artery may be avoided, and in order that the conditions at the back of the stomach may be early and fully investigated. After division of the great omentum as far towards the left as the point at which the stomach is to be divided, the whole organ is turned over the left edge of the parietal wound, until the coronary artery is brought into view and Ugatured with great ease at exactly the place required. As soon as this
CHRONIC GASTRIC ULCER i07
vessel is cut an anchor is "let go," and the stomach is moved more freely. Then while the stomach is held as a retractor an anastomosis is made between it and the jejunum. I now always apply the end of the stomach to the side of the jejuniun.
In my early cases I twice encountered a Httle diffi- culty in making the jejunum so apply itself to the stomach as to avoid a kink at the upper end of the anastomosis. In both cases some biUous vomiting occurred. In order to prevent this I now usually divide the jejunum com- pletely across, about eight to ten inches below the duo- deno-jejunal flexure, close the distal end, and make an anastomosis in "Y." This takes a few minutes longer, but the expenditure of time is worth while. The results are excellent. The condition after operation is remark- ably good; in almost all cases the patients have the most tranquil progress that one could wish. And not one sin- gle case I have ever operated upon has had a recurrence of trouble. Once the convalescence is complete the his- tory is without incident.
Whatever the operation from among all those men- tioned which may be selected in each individual case regard must always be paid to the power of the patient to bear it, and to its exact appHcation to the particular conditions disclosed when the parts are directly examined. Before the operation commences the surgeon should never reach a definite decision to perform any one procedure; he must apply at the moment of operation the method which best meets the indications in each case. And here, as elsewhere, the httle things count. Care in preparation, scrupulous exactitude in every detail, gentleness, dehbera- tion, with such speed as comes naturally from much practice, and is unsought as a special feature — all these
i08
ESSAYS ON SURGICAL SUBJECTS
together will sometimes turn what would otherwise be failm-e into easy and certain success.
Statistics
For the purpose of illustrating my practice in con- nexion with operations upon the stomach and duodenum I have collected together, with the help of my colleague, Mr. E. R. Flint, and my secretary, Miss Mackill, all the records of cases operated upon by myself since the year 1909, in- cluding the very lean years of war. Every case of simple disease of the stomach or duodenum (excepting acute per- foration) is included: cases of gastric ulcer, hom*-glass stomach, duodenal ulcer, and jejunal or gastro-jejunal ulcer following upon gastro-enterostomy.
The cases of ulceration* are as follows:
Ulceration
Grastric ulcer alone
Gastric ulcer with duodenal ulcer (including some cases
of hour-glass stomach)
Gastric ulcer alone causing hour-glass stomach
Duodenal ulcer alone
Pyloric ulcer
Jejunal or gastro-jejunal ulcer
Cases.
Deaths.
|
196) |
|
|
37 H |
7 = 2.7% |
|
23 605 9 33 |
3 = 0.49% 0 2 = 6.0% |
The greater severity of cases of gastric ulcer as com- pared with duodenal ulcer is strikingly shown; and the serious nature of cases of jejunal ulcer is evident.
* The figures in these tables have been brought up to December, 1920.
CHRONIC GASTRIC ULCER
109
Operations Performed
Operation.
GMtxectomy .
Gastxo-enterostomy —
Posterior
Anterior
In"Y"
In "Y" with jejnnostomy
With gastrostomy
(All these combined in a great majority of cases with removal of the ajj- pendix, and several with operations upon the gall- bladder. In two ovariot- omy was performed also.)
Ebccision of gastric or duo- den£d ulcer with or with- out gastro-enterostomy, including Balfour's opera- tion.
Hour-glass stomach (mul- tiple operations, gastro- enterostomy with gastro- gastrostomy, etc.).
Jejunostomy .
Caises.
100
} 738
19
Deaths.
2 = 2.0%
■!=\%
One case of almost total gastrectomy for large mul- tiple ulcers, eroding the pancreas and the Uver.
Five deaths were due to lung compUcations, associated in one with tuberculosis.
Remeu'ks.
The fatal case was one of duodenal ulcer; cholecys- tectomy and appendicec- tomy were also performed.
Post-mortem report: "Ex- treme fatty infiltration of right auricle and ventricle, cbronic fibrosis of kid- neys."
The fatal case had a gastro- jejunal ulcer of l8U"ge size, with much induration around it. The patient was exceedingly ill, and suffering intense pain.
Summaiy There were in all 905 operations, with 12 deaths — a total mortality of 1.32 per cent. Excluding the cases of jejunal ulcer there were 872 operations on cases of gas- tric and duodenal ulcers, with 10 deaths — a mortahty of 1.14 per cent.
References. 1 Lancet, 1920, i, p. 698. * Annals of Surgery, 1920, i, p. 303. * Jown. Amer. Med. Assoc., 1914, Ixiii, p. 1184. * Annals of Surgery, 1919, Lex, p. 522.
DISAPPOINTMENTS AFTER GASTRO- ENTEROSTOMY
Every operation in surgery, even the best, most ex- quisitely performed, may bring its disappointments. The operation of gastro-enterostomy, carried out in appro- priate cases by a competent operator, is probably the most successful of all surgical procedures of equal magni- tude, and it is certainly among the safest of those entitled to the description of major operations. In my last series of more than 300 non-mahgnant cases I have not lost a patient, and in recent years a temporarily unsatisfactory result has been extremely rare.
When we speak of disappointments after gastro-enter- ostomy, we must first remember that it may not be the fault of the operation but of many other circumstances if things go wrong. The success or failure of an operation may be due not only to the procedure itself but also to its performance in cases which did not need it.
It falls to my lot to see many cases in which the opera- tion of gastro-enterostomy has failed, and in reviewing these I find that they are capable of tabulation in the following manner:
A. THE OPERATION HAS BEEN PERFORMED IN THE ABSENCE OF ANY ORGANIC LESION JUSTIFYING IT
This is by far the most frequent cause. In every ten cases of unsatisfactory results nine are due to this cause and to this alone.
Reprinted from the British Medical Journal, July 12, 1919. Hi
ii2 ESSAYS ON SURGICAL SUBJECTS
The conditions for which the operation has been need- lessly performed are two:
(a) In Functional Disorders of the Stomach
The more we know of organic diseases of the stomach the fewer do those cases formerly considered fmictional progressively become. It is not so long since a patient suffering from duodenal ulcer, for example, was fre- quently told that he was the victim of "acid gastritis," or "acid dyspepsia," "hyperchlorhydria," or "neuralgia of the stomach," all of which were said to be functional states.
When I first called attention to the symptoms and to the clinical diagnosis of duodenal ulcer, I found it difficult to persuade many of my friends that I was speaking of a common organic lesion which could be demonstrated during an operation to any inteUigent onlooker.
To-day every one agrees that these symptoms are in truth due to a structural lesion and not to a vice in the chemistry or a defect in the motility of the stomach. And this holds good of other "functional diseases" of the stomach also. Inquiry upon the operation table reveals organic causes.
There still remain, however, a number of difficult cases of functional troubles associated with atony of the stomach or prolapse of this and other abdominal organs. Such cases may be difficult to treat by medical means, massage, exercises, and so forth; but they are often made very much worse by the performance of a short-circuiting operation. If such patients vomited before, they vomit still, though the character of the vomit is altered by the addition of large quantities of bile. In a few instances the patients wiU say that they are neither better nor worse, and I have
GASTRO-ENTEROSTOMY ii3
known one or two who incline to think their condition a little better than it was before operation. But the excep- tions are very few to the rule that in these conditions surgical measures are harmful or disastrous.
In such patients the only further operative treatment which the surgeon should undertake is the reparation of the mistakes of his too enterprising predecessor. The anastomosis must be undone, and the stomach and intes- tine returned as far as possible to their original condition. If there is a moderate degree of visceral prolapse great reUef may be obtained from the appHcation of a Curtis belt or of corsets.
(6) In Cases of Chronic Disease Elsewhere
For several years I have endeavoured on many occa- sions to emphasize the importemce of verifying, after the abdomen is opened, the original diagnosis of ulcer of the stomach or of the duodenum, before beginning any opera- tion designed to relieve the patient of his symptoms. An ulcer of the duodenum or of the stomach, if the cause of symptoms so long continued, or so severe as to justify an operation, is always a visible, demonstrable, palpable lesion. If no ulcer is found no operation should be per- formed. The day is long past when a surgeon is entitled to accept a chnical diagnosis, however confidently made, as a sufficient warrant for an operation. The lesion sup- posed to exist must be recognized at the time the abdomen is opened before any further steps are taken with the intended operation. This rule, which should appeal to every one, is still violated with no httle frequency. If no ulcer is found, a search should then be made elsewhere in the abdomen for a possible cause of those symptoms which have been attributed to a chronic ulcer. Failure to ob-
lU ESSAYS ON SURGICAL SUBJECTS
serve these precautions, and to remember this unalterable rule, has resulted in the performance of gastro-enteros- tomy for conditions remote from the stomach. The operation of gastro-enterostomy has been performed for the following diseases:
I. Chronic Appendicitis
This is the commonest of the mistakes in this class. Many physicians and surgeons have long realized how exact the mimicry of the symptoms of ulcer of the stomach or of the duodenum may be in cases of chronic appen- dicitis. Nine years ago^ "appendix dyspepsia," a condi- tion in which symptoms closely resembling those due to gastric ulceration were caused by a chronic lesion in the appendix, was described, and special attention was called to the presence of haematemesis or melaena in these cases. Haematemesis is more common in other diseases than in gastric ulcer, of which it is not a very frequent symptom. The occurrence of haemorrhage should therefore raise at once a suspicion not only of ulcer, but of chronic appen- dicitis, splenic anaemia, or cirrhosis of the liver.
II. Tuberculous Disease of the Intestine
Tuberculous disease of the ileum, or caecum and ascending colon has been present in a small number of cases where gastro-enterostomy had been performed in the absence of any ulcer of the stomach or duodenum.
Tuberculous disease of the intestine appears to be a common disorder in England and in Scotland. The im- purity of the milk supply, of course, is responsible for this. Manchester has recently discovered that 35 per cent, of the milk brought to it contains living tubercle baciUi, and
GASTRO-ENTEROSTOMY U5
a similar alarming discovery could doubtless be made in other towns if inquiry were instituted. The symptoms produced are, as a rule, clear evidence of tuberculous disease; but occasionally a patient may present such symptoms as make a diagnosis of duodenal ulcer not impossible. There are pyloric spasm, hyperacidity, pain, and vomiting. I have found tuberculous disease of this kind in two medical men who beKeved themselves to be the subject of duodenal ulcer, and whose belief was strengthened by other opinions. Both were a Httle dis- mayed when they learnt that gastro-enterostomy had not been performed; but both, I am glad to say, are cured by their operations. I have had one patient sent to me as a case of "gastric ulcer" upon whom I performed colectomy for hyperplastic tuberculous disease of the caecum.
III. Cholelithiasis, or Carcinoma of the Gall-bladder
Cholehthiasis, in all cases except those in which a single cholesterin stone is present, declares its presence, even in early stages, by the symptoms of dyspepsia, and often also of hyperacidity. The pain of flatulence and of heaviness comes with fair regularity about half an hour after a meal. There may be vomiting, and there is often much complaint of acidity. A very large proportion of the cases of chole- hthiasis, at a time when no cohc has occurred, are diag- nosed as cases of gastric disease.
The way to prevent this, and so many other mistakes, is to examine all parts of the abdomen likely to be affected by disease, before the purposeful part of the operation is begun.
il6 ESSAYS ON SURGICAL SUBJECTS
TV. Cirrhosis of the Liver, with Haemorrhage
In cirrhosis of the liver there is often dyspepsia; flatu- lence, heaviness, soreness, frequent eructations, with loss of appetite and a foul tongue, are common symptoms. Hsematemesis or melaena, or both, may be profuse. The absence of orderly development and precision in the time and character of the symptoms makes the differential diagnosis between cirrhosis and duodenal or gastric ulcer rarely difficult.
V. Splenic Anaemia
I have known a short-circuiting operation to be per- formed in this disease. The haemorrhage is often very abundant. The most copious haematemesis I have ever seen occurred in a patient suffering from this condition upon whom I was asked to operate for duodenal ulcer. I have twice removed the spleen in cases of splenic anaemia from patients who were sent to me as cases of duodenaJ ulcer. In both no ulcer nor any scar was seen.
VI. Tabes Dorsalis
I have seen five patients who were operated upon in this disease after a mistaken diagnosis of "gastric ulcer" had been made. The gastric crises, and the other dys- pepsias seen in tabetic patients, have so Httle akin to the symptoms produced by organic diseases of the stomach that there is no excuse for the mistake. I have had one patient who, suffering from tabes, had also the symptoms of duodenal ulcer. I operated upon him, demonstrated the ulcer, and performed gastro-enterostomy.
GASTRO-ENTEROSTOMY HJ
VII. DISSE^^NATED Sclerosis
I have seen one patient with this disease upon whom gastro-enterostomy had been performed; the surgeon found no ulcer, though the symptoms had suggested its presence to him. In the crises of the attacks of pain the stomach became greatly distended.
VIII. The Vomiting of Pregnancy
I have known two patients submitted