CHAPTER II In the later eighties, I had about determined to make my (Part 5)

to be deri\ed by the patient ? When one has had cases enough — and that is the main point — he will find that every now and then the microbe has tripped him up in the simplest of cases. The alert microbe is ever ready to slip in, and a very little mistake in judgment or error in technic in a quite simple case may allow the microbe to introduce a large feature of sorrow and regret into the case. Our arguments and "charge by the TO-MORROWS TOPICS court" may be all right, but we are always at the mercy of a socialistic microbe jury. At the time in life when we are most ready to operate, we are least well equipped for exercising judgment about the actual necessity for operation. Aside from the microbe, other little things may make trouble unexpectedly. Some years ago I had to do a trifling opera- tion for a beautiful young woman who was about to be married. There was a small linear ulcer of the common sort in the grasp of the vesical sphincter, which was to be cured in the customary way by dilatation and the application of a drop of nitrate of silver solution. When introducing the dilator there was a sudden spasmodic movement to which I paid little attention, but the dilator when removed was not followed by the gush of boric acid solution as anticipated, and I at once realized that vesical rupture had occurred as a result of spasm. The customary steps were taken instantly, but this young woman died three days later from acute general peritonitis. One of my acquaintances among the "occasional operators" set out to remove a small branchial cyst from the neck of an only daughter who was very popular in the younger social set in New York. He depended upon local anesthesia, and was not quite familiar with the fact that the wall of these cysts is often associated intimately with the jugular vein. When pulling up the little cyst, he pulled up the wall of the jugular vein and excised a segment of the latter with his scissors unwittingly. The steps for an immediate operation which were now called for could not be followed in the area which was under the influence of local anesthesia. The operator lost his head and the patient died in the course of a few minutes from hemorrhage. Neither one of these accidents would have happened to more experienced surgeons in the TO-MORROW'S TOPICS 91 first place, and in the second place, better-trained surgeons would have saved the life of one or perhaps of both patients, even if the accidents had happened. The majority of medical patients as well as surgical patients get well anyway, no matter what is done to or for them, and physicians through all history have taken credit to themselves for results which nature was bound to accomplish, very often in spite of the treatment which was employed and which was really antagonistic to the patient's interest. When making reports upon cases it is extremely important to report upon both sides of a question. The profession is very suspicious if one reports good results only, forgetting about the others. It is much more important to report deaths and accidents than to report a series of good results if one is not recording a consecutive series of cases. Consecutive cases are the only ones which are really valuable for statistical purposes. It is important also to publish a report of one's mistakes in diagnosis. Some of my mistakes have allowed other surgeons to think of right things in response, and of which they might not have thought otherwise. Cabot of Boston made a report upon post mortem examina- tion in three thousand cases in which antemortem diagnoses had been made by physicians of a representative class. Correct diagnosis varied from 16 to 95 per cent., according to the sort of disease. Diabetes mellitus was diagnosticated correctly in 95 per cent, of the cases, although this in itself is only a symptom. The symptom of diabetes mellitus simply indicates that it is high time for us to make a real diagnosis in the case. T)rphoid was diagnosticated correctly in 92 per cent, of the cases reported by Cabot, aortic regurgitation in 84 per cent., cancer of the colon 74 per cent., thoracic aneurysm 50 per gj TO-MORROW'S TOPICS ctnt., tuberculosis of the kidney 33^4 per cent., acute peri- carditis 20 per cent., acute nephritis 16 per cent If this is the proportion of correct diagnoses of the sort of physicians who furnished Dr. Cabot's statistics, — 3. well educated and con- scientious element in the profession — the number of incorrect dia{ni<>^s made daily by physicians in general must be pretty large. Some of the irregular practitioners and faddists would have almost no correct diagnoses at all to their credit Their nutients who recover do so through the vis tnedicatrix naturae, plus treatment of symptoms. l^ie is not to be blamed for making mistakes in diagnosis, unless he is careless. That is inexcusable. I do not know of a case in which any one of my own mistakes in diagnosis has Ut^n actually injurious to the patient, but some of them might have l>een. On one occasion I was called to a distance in a ^Ase itt which some of the physicians believed gall stones to l< present. The patient appeared to be cachectic, with a historv of the loss of about fifty pounds in weight She was xerv feeble and had an irregular immovable mass in the gall- hl4\lder region which I took to be cancer. The opinion was ijiven that the case was one of cancer, not operable, and the L^t plan winiUI be to allow the patient to have all of the \n^hine that she required in order to make her remaining w»As oi Hf<^ «'' ^"'^ ^^ comfort as possible. The case soon I ^^1,1 of mind, and it was perhaps three months after- T\ when I liapi)cne(I to meet one of the physicians and ^ . . |jj„| how long the patient had lived. He replied, "Oh, iwnt to write you. When we began to give her morphine uir sUKK^'**^^^"' ^^ apparently caused relaxation of a VA jj^» ^-ondition of the cystic duct. Something at least 2J^^^I She passed a large gall stone, and has got back ^^^ \f her wciglit and is in better health than for many years TO-MORROW'S TOPICS 93 One amusing mistake occurred when a doctor called me to assist him at an appendix operation, asking if I would stand by to make suggestions while he did the work. After exam- ining the patient, my diagnosis was that, in view of the patient's advanced age, the long history of the illness, the comparatively mild beginning, the cachexia, and the presence of a movable mass in the cecal region, he was probably dealing with a cancer of the cecum rather than appendicitis. An excision of the cecum was advised. The doctor said in that case he preferred to have me do the operation, as he did not feel prepared to do anything quite so extensive. Incidentally I would remark that right here is where a great many "occa- sional operators" make dreadful mistakes. Imagining them- selves to be qualified for doing an operation for appendicitis and yet not prepared to do a bowel excision, they must some- times find themselves with an appendix operation requiring a great deal more technical skill and nice judgment than would be demanded for an ordinary bowel excision. My reply was that if we were to do an operation of this sort, the patient should be at the hospital instead of at her home. She was moved down in the ambulance and the operation was done in the presence of my class at the college. I carefully described the differential diagnosis between appendicitis and cancer of the cecum, and then upon operating found that it was really a case of appendicitis with perforation, and a concretion in the walled-in abscess cavity. Unsuccessful cases often remain unreported by men who are honest by nature and training, but who are discomfited by failure and do not like to think of the subject even when all alone. They may mean to report the cases, but time goes on and it is not done. If it is one's wish to be really helpful to the profession, he must make a point of reporting all of his important mistakes at society meetings at least. Nothing is 94 TO-MORROW'S TOPICS more injurious than having a reputation for reporting suc- cesses only. In one of my cases of mistaken diagnosis of appendicitis, a patient from a distance gave a very clear history of an acute attack foUowed by such a degree of abdominal tenderness and resistance that we could not palpate well. I was under the impression that we were dealing with a chronic abscess in the vicinity, subsequent upon an acute attack. Upon opening the abdomen the peritoneum and appendix were found to be perfectly normal. It was a case of hysteria major in which the patient had chosen to deceive us, and had learned the symptoms of the disease for purposes of recital to us. I am always on guard against these traps of hysteria major, but made a mistake that time, and finding the tissues normal proceeded to replace the appendix within the abdomen. The patient's physician who stood by my side and who had come on with her from a distance asked if I were not going to remove the appendix. I replied that it would be against my principles to do so. He said that he could not take her back to the town from which they had come, with a statement of the facts in the case. I told him the better way was to state the exact truth, because that would be explanation enough, but he replied, "No. I cannot do that. I will say that you took out the appendix, but will not say that you put it back again." In any event there was nothing more to be said, and the patient and her physician returned home at the end of a couple ■>f weeks. She was entirely cured of her symptoms for the ime being. A year or so later she was taken to a Buffalo rgeon for some supposed ovarian trouble demanding imme- :e operation. He was deceived as I had been, and while ng the abdomen open thought it would be interesting to to the cecum and see the result of my former operation, hich she had told him. Finding the appendix normal TO-MORROW'S TOPICS 95 and not removed, he thought it a very good joke, which was quietly passed about for some time until I incidentally heard of it a year or so later. Once when opening the abdomen of a young girl and finding that we apparently had a morbid growth to deal with, and what appeared to be malignant papilloma of the peritoneum, I at once closed the abdomen, and said to the friends that the girl could not live more than a couple of months, as her case was hopeless. Other consultants had tried to help her and my opinion was held to be final. A hopeless prognosis having been given, the family yielded to the importunities of friends and allowed the patient to be taken in charge by a Christian Scientist. She rapidly became well and gained some forty pounds in weight. On hearing of this I examined for the first time a specimen which had been removed at the time of operation, and found that the case had really been one of tuberculosis of the peritoneum all along. Patients not in- frequently recover from this condition as a result of simple opening of the peritoneal cavity. The hyperleucocytosis which is excited by opening the peritoneal cavity leads to destruction of tubercle bacilli. I had been so sure of the diagnosis of papilloma that the specimen had not even been sent to the laboratory for examination at first. The Christian Scientists had a fine case for quotation as a result of my mistaking a rare form of tuberculosis for papilloma. In my early appendicitis work one of the patients who was lost had a small chronic abscess remaining after her appendix had sloughed. When hunting conscientiously for the appendix among extensive adhesions, so much injury was caused that the patient died as a result. At the present day the situation would be recognized at a glance, and such a patient would ordinarily be out of bed and well along the road toward 96 TO-MORROW'S TOPICS recovery in the course of ten days. The appendicitis operation is sometimes far from easy in cases in which it may at least ^be made safe. Knowing when and where to stop in the course . of an operation is one of those difficult things which tax the I judgment of the most experienced surgeons. Hundreds of patients are lost every year because their surgeons did not have the experience and training requisite for letting them know just when to stop in the course of a given operation. Early in practice there was once occasion to remove a scarred fibrous tonsil for a youth. It was drawn too far forward with the tenaculum, and while it was being severed with a scalpel. the carotid artery was opened. I was all alone without medical assistants, and had even given the anesthetic myself, asking a member of the family to lend an unskilled hand later. Relat- ing the occurrence to a friend shortly afterward, the state- ment was made that the carotid stream went to a wall of the room ten feet away. He reminded me that the carotid could only throw a stream half that distance, and my estimate represented a state of mind rather than a measured distance. The accident caused the patient no harm of consequence. In fact he was never told about it. While thinking of accidents a case comes to mind in which a large ovarian tumor was to be removed at a farmhouse. We had bowls of antiseptics and various appliances on the same table upon which the operation was being done, — one of the common kitchen tables with leaves. The room suddenly grew I very dark because of an approaching thunderstorm, and two I large lamps were mo\ed to the table. Just as we were in the I midst of the operation one of my assistants leaned too heavily I iqion the table, breaking it in the middle. Patient, bowls of I antiseptics, lamps, blankets, and all of the rest of us tumbled Pinto one heap. One of the lamps blazed explosively over the tatient's open abdomen and had to be smothered with a TO-MORROW'S TOPICS blanket. We managed to straighten things out and completed the operation upon the floor of the room. The patient made a good recovery. On one occasion in a village an enormous tumor had to be removed with the help of three unskilled assistants. Two of the doctors boasted of having served in the war of the Rebel- lion. The work was partly done, when in the midst of details requiring greatest assistance, one of the war doctors fainted, and had to be stretched out upon the floor. The anesthetist then began to feel faint, and I was obliged to complete the work alone without operative assistance, because the only re- maining assistant had to give the anesthetic. One might fill a very large book with tales of odd experi- ences and only a few which happen to come to mind are quoted here. Many years ago a patient with dysmenorrhea wished to have a flexion straightened, but her husband objected to having any operative work done. One day she sent word that her husband was away for the day, and she would like to have us do the proposed work. Dr. J. S. K. and I repaired to the house. We decided not to use ether because it would leave a tell-tale odor. Chloroform was chosen instead and hur- riedly given. We were just on the point of beginning the work when the patient suddenly died. Dr. K. threw her knees over his shoulders while I made artificial respiration and resorted to various tactics for arousing heart action. During at least ten minutes there was not the slightest re- sponse. Then a slight gasp made the very sweetest sound we had ever heard in our lives. Ten minutes later the patient was breathing and we completed the operative work. To this day the patient does not know of our experience and her husband does not know that the operation was ever done, but Dr. K. and I remember. It was a very rash procedure on the part of two young doctors, and we would not think of 98 TO-MORROWS TOPICS taking any such chances to-day, no matter what justification might be offered by the circumstances of a case. The first medical case in which I ever became interested occurred during student days at the University, long before taking up a medical course. A poor boy who lived near where we went bass fishing was supposed by the doctors in charge to have hydrophobia. The newspapers described it that way. The boy lay in a nearly unconscious condition for several days, and when anything was moved near his face, would growl and snap at it like a dog and froth at the mouth. On account of my interest in the boy I went to the library and read up on the subject of hydrophobia, and decided that the patient did not have this disease, but something else. It seemed to work out as a case of some nervous derangement. The boy simu- lated the fancied action of a mad dog. Incidentally when looking up the