BY DR. ROBERT T. MORRIS.
Publisher: Geoffrey Bles.
A patient usually retain a great fund of natural resistance during the first fifteen minutes of an operation, no matter what is being done. He is usually depressed after an hour of operative procedure, no matter what is being done. It seems well, therefore, for us to attempt to keep within the fifteen- minute limit wherever possible.
Early in my operative career I noticed that a number of surgeons used so many instruments it made confusion for assistants. To show my class that operative surgery was, after all, a simple matter, I would sometimes do three of four abdominal operations in succession, using only a pair of scissors, a needle and an artery forceps, sometimes even dispensing with the forceps.
Other instruments, of course, were sterilized and ready for use in case of necessity. My assistants and members of my class knew very well what I was trying to teach, but other surgeons felt that I was “simply doing a stunt”.
The sense of touch is far more accurate than the sense of sight because it is more intimate. A trained finger among adhesions gets “the rebound” from a buried ovary or gall-bladder a long distance away. My old friend Joseph Price, the most dexterous abdominal operator I have ever seen at work, said that when he got among complicated adhesions he always felt like asking someone to blindfold about his eyes.
Working by sense of touch among adhesions, one may locate a buried oviduct in a few seconds, when many minutes might be required to find it by the sense of sight.
By touch, an appendix buried among adhesions may be whipped out in thirty seconds, where by sight thirty minutes would be required. In both cases, the visual operator is in constant danger of damaging a ureter or an iliac vein, which are easily enough distinguished by feel among the densest adhesions, but are indistinguishable visually.
I feel sure that in my early days of work with physicians who did not operate there were fewer deaths from appendicitis on the whole than there are to-day as a result of refinements belonging to modern experiment – plus incompetent surgery on the part of men who have been given a licence to do as they please.
I would be almost afraid to have appendicitis to-day; but such was not my feeling twenty years ago. In the days of my first observation of these cases, fifty years ago, they were most often called “inflammation of the bowels” by certain old-time doctors, whose pneumonia cases were “inflammation of the lungs.” Superior consultants needing to make an impression in that day referred to cases of inflammation of the bowels as ones of typhlitis or perityphlitis. Some of the patients were very ill or had recurrent attacks.
They moped around for months, perhaps, with tedious convalescence or with some degree of permanent crippling of the bowel. They, nevertheless, muddled through somehow, as a rule, as far as really living was concerned. Of course, no one knows how many died years later from impression made upon heart, kidneys, or mucous membranes by toxins resulting from chronic bowel disturbance.
The death-rate and morbidity rate in appendicitis treated by master-surgeons to-day becomes almost negligible when compared with the results of the best medical treatment, but master- surgeons are not usually in charge. By morbidity rate I mean the length of time expended in convalescence, and bad results caused by complications like post-operative peritoneal adhesions or post-operative hernia. There is no question about acute appendicitis being a surgical disease. The question is now: Which surgeon? Thats all!.
A number of deaths in appendicitis follow minor errors of technique. The amateur surgeon ties the stump of mesentery of an appendix too short. The ligature on so short a stump slips off when the patient gives too hearty a laugh. Haemorrhage from a small artery may not be very apparent for some hours, and these patients are likely to die in the night, when everybody is sleepy.
The only suggestion of mine that was ever instantly taken up all over the world was a bad one. Certain laboratory workers had included peroxide of of hydrogen among the germicides, and I set out to experiment with it in practical application for the cleansing of wounds.
In the right place and when employed by the right surgeon this germicide has special value. But peroxide of hydrogen, when destroying microbes and septic fluids, destroys at the same time granulation tissue, new epithelium, and new protective cells. Used just once for first treatment of a foul septic cavity or for the purpose of loosening adherent first-aid dressings, there is nothing to take its place so far as I know.
When applied for cleansing purposes in a wound that is undergoing repair, or as a first-aid antiseptic, or as a mouth-wash or gargle, the injury to normal cells may become a very serious matter. Delayed repair of wounds is an almost daily spectacle where doctors, nurses and laymen are charmed by the gross cleansing abilities of this germicide. The subject should never have been “released” at all – the bad effect has more than offset its value.
Doctors sometimes get into trouble from forgetting the potency of a tiny graft that is unintentionally left behind when the pedicle of an ovary is ligated, leaving behind a few ovarian cells. Nature is so insistent upon retaining the mechanism of reproduction that she promptly sets this tiny graft into activity; if there are not cells enough to please her, she may call into action latent cell “rests” in the broad ligament. My very first abdominal operation turned out in that way. It was when I was a student in comparative anatomy at Cornell about 1878. Harry Clark, a restaurant-keeper, owned an Irish water- spaniel that the family loved deeply.
Unfortunately she was in the habit of having an abnormal number of puppies in each litter, ten or twelve of them; the delivery always carried her near to death from exhaustion. I was asked to remove her ovaries. At the next litter she had fourteen puppies, the largest litter of all. Dr. James Law, the veterinarian, years later performed a post mortem examination and found that a number of discrete ovarian cell “rests” in the broad ligaments had apparently gone into action in a way to supplement lost ovaries.
No one can be a 100-per-cent. doctor until he has himself had some serious illness or surgical operation. This is not a prescribed feature of the curriculum at medical college, but was one of the things that I learned after graduation, and more important than any single thing acquired from teachers. Instructions tell us nothing of the feel of fresh bed-linen without wrinkles after a sleepless night; of bed utensils thoughtfully warmed by the nurse, or the comfortable feeling of security in the mere presence of a nurse in the room.
They tell us nothing of the effect of the cheery doctors visit – the best moment in the whole day or night, when our response is so bracing that the doctor himself is always deceived about our real condition. Neither do our teachers tell us anything of the soft and gentle touch of a loving, sympathetic hand or of visits from friends who we supposed had forgotten us entirely. It is well to be ill-for once, anyway.
Dr. C.G. Stockton of Buffalo, as general practitioner, once sent me a case of choroiditis in a clergyman who had become too blind to continue his work in the church. Dr. Stockton felt that the eye condition might be toxic and secondary to indigestion caused by chronic appendicitis. I removed an irritating appendix undergoing fibroid involution. Indigestion was brought under control; the choroiditis was cured; and the clergyman went back to his pulpit.
A Canadian clergyman with depression of the frontal bone resulting from a horse kick developed epilepsy, which obliged him to give up the pulpit, despite medical treatment. I elevated the depressed bone and separated dural adhesions with the result that his epilepsy was reduced to trifling attacks, and he resumed his work. The benefit appeared to be permanent some years later.
Another case of epilepsy which was improved, with resumption of occupation by the patient, after futile medical treatment was that of a millhand who had been thrown against a buzz-saw some years previously and received a deep cut through the frontal bone to the brain. A remarkable feature of that case at operation was the removal of a square inch or so of encysted old black felt hat.
Tell a specialist in nervous diseases that sciatica or dipsomania might be cured by correcting eye-strain and he may pooh-pooh the idea. Tell an ophthalmologist the same thing, however, and he will not only confirm the statement but will quote other things quite as interesting as a result of merely correcting an error of refraction. They do not know of each others work.
A specialist in stomach trouble may keep on for years giving eggs in the diet for a case of ulcer of the duodenum when the general practitioner might discover that the patient in this particular case was sensitized to the lipoid of egg, the basic cause for ulcer in that patient in the first place.
Sometimes it becomes difficult for young surgeons to know what charge to make for services rendered. They go to older men for advice. One of the younger doctors, Dr. Santangelo, was completing an operation just as I stepped into the door of the operating-room. A little later, meeting me in the hallway, he said, “I do not know just how to charge that patient. Please give me advice.”.
I replied, “You have given him permanent relief from a distressing condition. The work was nicely performed, and he should now be enabled to follow his occupation in good spirit. What is his occupation?”.
“He is a burglar. He will pay anything that I ask him to pay, but he will have to go out and get it. How much shall I charge?”.
Another difficult situation arose when my friend Dr. Brown left his surgery in a small town one evening and went out on the marsh to look for ducks. He was not a wing shot. Wading silently through reeds and cat tails he saw half a dozen ducks in a little opening and promptly fired at them. A man jumped up with a shout of pain from the cover behind them. They were decoy ducks.
Knowing that the small shot would not injure a man seriously at that distance, Dr. Brown, unrecognized backed out of the reeds in the gloaming, made his way back to the surgery, and had just changed his clothes when in came the man to have the shot taken out. To avert suspicion the doctor had to charge him twenty-five dollars.