CHAPTER V Every ambitious man has been impressed by certain lessons (Part 3)

sen- tences of ridicule but had a marked influence in accomplishing its object. As a phrase it carried a hook which exerted deter- mining influence upon the actions of men who tried to shake it loose. One objection to the short incision was that it required a degree of skill which many men did not know they really possessed until a little experimenting had been done. Sur- geons were divided into two camps — those who objected to the introduction of technical difficulties, and the ones who sought opportunity to exercise their own best degree of skill. For that matter, it is not best to persuade men who prefer easy work to engage in more difficult work. Such work would be badly done by a man who is forced by his conscience to attempt the exercise of a degree of skill for which he is not equipped. A Chicago surgeon of national reputation came on to New York to have a short incision appendicitis operation at the time when the controversy was most bitter. He was out of bed in about a week, and two or three days later happened to be call- ing upon a New York surgeon. Saying nothing of the operation which he had recently undergone he bi^ought up the question of appendicitis in general, and his friend said: "You know there is one d d fool here in New York — I can't think of his name just now— who says that he can operate through an inch and a half incision and let the patient get out of bed in a week. I keep mine In bed for more than a month." J 258 TO-MORROW'S TOPICS To tliis the Chicago surgeon made no response, hut highly amused told me about it an hour or so later. He said tliat he could feel his scar blush, but otherwise his entire equanimity was retained. While earnestly engaged in preaching against long incisions, multiple incisions, and gauze packing in appendix work I was often taunted good-naturedly by men of prominence. On one occasion, at an association meeting in the South, two surgeons while passing my seat asked if any invitation had been given me to go over to the hospital and show short- incision work. My reply was in the negative, and they laugh- ingly said: "We have been invited to go over and operate, and we are going to take plenty of room and put in lots of gauze." At this time I frequently heard of cases that had been headed in my direction and that naturally would have been mine, but that were turned aside. The patients were informed that peculiar things would be done to them, on principles that were not recognized by the profession. Sometimes physi- cians told me that they could not give me their cases because it subjected them to so much criticism. Many objections to the short incision idea were brought forward by surgeons who quoted cases in which that method would clearly be inac- ceptable. My answer was, "Make a salt mackerel incision a foot long if necessary, but allow patients to escape with the mildest attack of surgery which your skill can provide for them." That is still my answer to-day. All sorts of odd experiences intervened by fate to interfere for awhile with the short incision propaganda. When the question was hottest and needing timely blows to weld the I principles into shape I had arranged to meet several opponents k at Moscow. Two weeks had been allowed for getting there I from Halifax, but the ice drifted in upon my schooner on the |Labrador coast and kept me locked up until after the Mos- J TO-MORROW'S TOPICS 259 cow meeting at which my opponents were present, and had their say. Insistence upon prompt operation without argument in cases of acute appendicitis did me much harm in the early days of interest in this subject. It was assumed that a man so radical would wish to carry the same radical attitude into other kinds of operative work. As a matter of fact there are few men who are more fond of calling consultants generally and in getting together all available information relating to a given case. Cases of acute infective appendicitis however are always out- side of the limitations of judgment. They are always outside of the limitations of prognosis. In that class of cases I insisted upon the rule to "operate as soon as the diagnosis is made.'' Of late years other surgeons have told me of their being the first to lay down that rule, but during the days when it brought little beside discredit there was hardly anyone else whom *'it sounded like." When a doctor has established an idea and has led other doctors to think they did it themselves, his function is ended, and his mission done. Nothing but vanity prompts him to ask for recognition in the profession. In business he has a right to ask for recognition. That is one of the distinguishing features between a profession and a business. When in the course of diagnostic work I developed a method for palpation of the appendix, and published a report upon the subject, one of the most popular medical consultants in New York said that the normal appendix could not be pal- pated by anybody, and he looked upon one who made that claim as being presumptuous. He was told — perhaps a bit impatiently, — that he had no right to make a diagnosis or express an opinion when the question of appendicitis came up unless he was prepared to palpate a normal appendix in the average patient. No one can appreciate the far-reaching TO-MORROW'S TOPICS influence of a popular consultant in a city when he honestly holds that one who is developing some new point is making fanciful claims in regard to it. At the present time it is probable that the majority of consultants in this country can palpate a normal appendix in the average patient. It is simply a matter of having a method which makes success possible. and then developing a tactile sense when following the rules of the method. The statement that palpation of the normal appendix should be an accomplishment of every diagnostician was not harmful for so very many years, because there were too many members of the class at College who observed the results of palpation as demonstrated in the operation which immediately followed. A man with no family or families dependent upon him for support can much more heartily carry forward any new doc- trine. After all it is probable that doctors have an easier time than clergymen, who are often not paid promptly by their churches, who are paid low salaries, and upon whom very extensive demands are made by unreasoning people. Even their teaching is at the mercy of their leading parishioners, and it seems probable that the whole question resolves itself into one of success only for those who are by nature properly I adapted for their work anyway. One can hardly conceive of a man in the medical profession or in the clerical profession who could remain in that profession guided by any hope of reward beyond the reward of knowing that he was accomplishing his Ideals in one way or another. The clergyman can seldom maintain his ideals of honesty by paying bills within a reason- able time, if the church does not pay him. He is always having trouble with the choir. Gospel for one of his leading ' nafishioners is heresy for another leading parishioner, and his Hinnnpathy is most demanded by the neurasthenic who deserves ^K,l9a«b He has to give up many social pleasures which are TO-MORROWS TOPICS 261 quite innocent in order to conform to the ideas of some of his congregation. There is less of candor between the parish and the clergyman than between the head and the lesser officials in commercial business. The business man however has still more trouble than the clergyman, and some of the most learned of lawyers earn only a few dollars per day in the offices of more successful lawyers who are altogether too busy with large cases to find time for becoming learned. A surgeon who can make a fair living and at the same time be useful to the public occupies an enviable position, no matter if his trials are the greatest trials that he happens to know about. One of the most important features occurring in my work was perhaps the classification of appendicitis into four separate and distinct types. First, (the commonest form) an irritative lesion, — ^not in- fective, belonging to normal involution of the appendix, with fibroid degeneration which incidentally includes sensory nerve filaments engaged in hyperplastic connective tissue. This was called protective appendicitis because the irritation calls out local hyperleucocytosis at the same time when those struc- tures which are chiefly engaged in cases of infective appendi- citis are disappearing. The second form in my classification was intrinsic infective appendicitis. This form is less common than protective appendicitis, but the one which attracts most attention because of the violence of its processes. This form got to stand as a synonym for all appendicitis colloquially, although less com- mon than the first or comparatively harmless form. The third form, which was called syncongestive appendix citis, is like the first form, an irritative lesion and not an infective lesion. It consists in irritation from the presence of interstitial infiltrates which appear along with vascular I TaMORROW'S TOPICS disttirbances of other viscera simultaneously in a chronic way. TTie fourth tj-pe was cjrlrinsic infective appendicitis, and related to the extension of infection from neighboring struc- tures to the outer coats of the appendix. This process com- monly occurs slowly and seldom leads to violent destructive changes. We appeared to have then four separate and distinct types of appendicitis, two of them being irritative lesions, and two infective lesions. — the commonest lesion of all, and one which took the patient most often to the doctor's office, being least often one which really required operative procedure. Among other points apparently new was the idea that the chief menace in cases of infective appendicitis depended upon the narrowness of the appendix. Its outer covering of peri- toneum, and its muscular layer, do not become distended so rapidly as the inner lymphoid and mucous layers when any exciting cause leads to swelling of the distensible inner struc- tures within the tighter outer sheath. Compression anemia of inner structures results from their swelling within a tighter sheath, and these tissues, deprived of normal blood supply, become very vulnerable to attack from bowel bacteria, .^y- thing which leads to ordinary swelling of the inner coats — the presence of concretions— extension of a common colitis — torsion and damming — selective affinity for streptococcus toxins — and many other causes for swelling may precipitate an attack of acute infective appendicitis most unexpectedly. Whenever one starts off on any line of obser'ation he promptly finds more vistas opening from the same path. The results of trying to lessen the amount of surgical injury in the operative work of appendicitis brought saliently forward the facts of self-protective powers of the individual. Upon this observation as a basis, and through opportunity given by new data belonging to the Century, facts were assembled for TO-MORROW'S TOPICS 263 the purpose of establishing principles of a new era in surgery. This we may call the fourth or physiologic era. The first era was the heroic, dating in history from the days of Hippocrates or of the early Egyptians. Then came Andreas Vesalius and the anatomists who established the second or anatomic era of surgery. Pasteur and Lister introduced the third or patho- logic era, and this is now prevailing the world over. Metchni- koff and Wright brought forward new facts which I corre- lated for a basis upon which we may found the fourth or physiologic era in surgery. The dominant idea of the third or pathologic era (which is to disappear to-morrow) is to prevent the development of bac- teria in wounds and to remove the products of infection by means of our art. Inimical bacteria as well as body cells are composed of protoplasm. Both are simple morphologically but highly organized chemically, and in the course of evolution have come to be the peers of each other as a result of the struggle for existence. Anything which is destructive to the protoplasm of bacteria is likewise destructive to the protoplasm of body cells. Germicides which were introduced into our armamentarium during the pathologic era in surgery, have done an enormous amount of harm when employed without knowledge of the fact of their being injurious, not only to inimical bacteria but also to the body cells which should be physically free to resist the entrance of bacteria. In addition to the free use of germicides, detailed work which had for its pur- pose the removal of products of infection, exhausted the natural store of energy of the patient so that he was less well equipped for taking up the fight against bacteria. Further than that, our confidence in measures for securing asepsis and anti- sepsis, — together with improved methods in anesthesia, — led us to forget that when operating we were at work upon a living sentient organism. Operations which might have been com- 264 TO-MORROWS TOPICS K ced pleted in twenty or thirty minutes were often extended to an hour or two hours in duration, in order to allow per- fection of detailed operative technic. We did not realize that energy granules were going out of the patient's brain and nerve cells like steam out of an escape valve while this work was going on. We did not fully understand that all of the machinery of the ductless glands, arranged bj' nature for purposes of meeting infection and conducting repair, was being thrown out of gear at the time when the store of reserve energy of brain and nerves of a patient was being let off and wasted. When Metchnikoff and Wright came into the fields of pathology and physiology with their description of phagocytes and opsonins, there seemed to me opportunity for making a review of the entire subject of operative surgery, in the idea of founding a new general method of procedure based upon physiologic principles. According to the principles of the fourth or physiologic era we were to conserve the natural resistance of the patient and to turn him over to himself — to his own phagocytes and antibodies— as quickly and help- fully as we could. It is the home rule idea. The surgeon is merely to turn the tide of battle between bacterium and body cell, leaving the patient with his normal physiology as nearly intact as possible. "Get in and get out" was the legend which I applied for purposes of brevity when describing the leading idea of the physiologic era. My first formal presentation of principles of the fourth era of surgery was made in the Sec- tion of Surgery and Anatomy of the American Medical Asso- ciation, in 1908, and at the following International Medical Congress, in Budapest. Observations which ted to a grouping of data for purposes of estabhshing principles of new pro- cedure were published in 1910 by Saunders, in my httle entitled "Dawn of the Fourth Era in Surgery." This ittle book M Phis con- H TO-MORROW'S TOPICS 265 sisted of various articles previously published and aiming at a general conclusion. There is no need for detailing any of the points here, ex- cepting in a brief way. When proceeding step by step with methods which conserved the energy of the patient, I soon found myself running against established principles of the third or pathologic era. Operations which were conducted quickly were said by critics to be carelessly performed opera- tions, because of the neglect of technical details. Operations conducted through short incisions were held to be incomplete, because "they failed to expose all of the pathology," — quoting a familiar form of expression. Operations which failed to allow thorough removal of products of infection were con- sidered by competent surgeons in the light of extremely risky procedures, and diametrically opposed to all of the spirit of present-day surgery. (Curiously enough it was this present- day surgery for which I had made my first and most vigorous fight when entering the profession — and against the almost united opposition of the majority of the leading surgeons at that time, ) Observations leading to the arrangement of data for estab- lishing physiologic surgery were based upon a few main points, Lawson Tail had presented better statistics than any other abdominal surgeon in the world, at a time when some of us were enthusiastic over antiseptic surgery and he was railing at it. His results called for explanation which we could not then give. It seemed to me that he was conserving the natural resistance of his patients through rapid operating and the infliction of a small degree of surgical injury. It looked very much as though his patients with retained natural resistance were meeting infection better than the patients of the rest of us, with our long drawn out and carefully con- ducted technic of new art that was based upon the best science I 266 TO-MORROW'S TOPICS of the day. Added to the statistics of Tait was the fact that patients with purulent collections in the peritoneal cavity sometimes recovered without operation. That again was testimony in favor of the idea that the patient himself was enabled to conduct some pretty good germicidal work. Ochsner's so-called starvation method, in appendicitis with spreading peritonitis, still further indicated that the patient exerted a great deal of control over violent infections if he were not disabled by surgical shock at a critical time. The simplest big fact that surgeons had overlooked was