CORNELL UNIVERSITY THE 3flDtupt Hctetitiatg library FOUNDED BY ROSWELL P. FLOWER for the use of the N. Y. State Veterinary College 1897 This Volume is the Gift of ..Br.....Lao.n,...Si-...Bea;rd«lev The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000347744 IN PREPARATION. Surgical Diseases of the Head, Face and Neck — Their Diagnosis and Surgical Treatment By a. C. Bernays, A. M., M. D, About 350 pages. Many Original Illustrations. Royal octavo Price, $6.00. THE C. V. MOSBY MEDICAL BOOK CO., Publishers ST. LOUIS, MO. Medical Guides and Monographs Series. GOLDEN RULES OF SUEGEEI APHORISMS. OBSERVATIONS AND REFLECTIONS on the Science and Art of Surgery. Being a Guide for Surgeons and those who would become Surgeons. BY AUGUSTUS CHARLES BERNAYS. A.M.; M. D. , Hdlbg. , M. R. C. S. , Eng. Life Member of the German Society for Surgery of Berlin, Chief Surgeon Lutheran Hospital, and for Twenty Years Professor of Anatom.y and Surgery in St. Louis, Mo., U. S. A., Member American Asso- ciation for the Advancement of Sciences, of the St. Louis Academy of Sciences, etc. ST. LOUIS THE C. V. MOSBY MEDICAL BOOK CO. 1906 Copyright, 1906, by C. V. Mosby. TO MY FRIEND CHARLES H. MAYO, M. D., OF V ROCHESTER, MINN., WHOM I ADMIRE AS A SURGICAL ARTIST, I DEDICATE THIS LITTLE BOOK. HE HAS EYES THAT FEEL AND FINGERS THAT SEE. HE TEACHES ALL .THAT HE HAS LEARNED IN THE ONI^Y POSSIBLE WAY ONE MAN CAN TEACH ANOTHER— BY LETTING THE OTHER SEE HIM WORK ; AND HE WEARS NO CLOAK ! « PREFACE In this guide to the study of surgery, short space compels me to deal only with the important and frequent occurrences, and not with rare cases. Throughout the little volume will be found philo- sophical canseries. May they amuse the reader if they fail to convince him. If I may guide the student and keep him on the scientific track, I shall be content. Many of the rules are taken from the fine selection of Golden Rules of Surgery, by Hurry Fenwick, F. R. C. S., England. I have altered them to suit my views and have added much new material. Rules on some subjects, for instance on genito-urinary sub- jects, are quoted unchanged. and in toto. I desire to express my indebtedness to this author. On all doubtful or new matter, I give my views based on my own experience, whether differing from accepted views or not. My experience of thirty years has been interspersed by frequent visits to my most renowned colleagues, both in this country and abroad. My judgment has been broadened and tempered by these annual voy- ages, and still I am often in error because I am only human. A. C. BERNAYS. St. Louis, Mo., April, igo6. CONTENTS Page Preface 5 The Education of a Surgeon - 9 On Scientific Contributions to the Liter- ature OF Mebicine and Surgery - 21 Science and Surgery - - 37 On Ways and Means of Building up a Practice - 43 About Fees - 50 Off with the Cloak of Superstition 52 Some Golden Rules of Surgery - 59 Away with Inflammation and the Con- fusion It Has Caused 173 Reminiscences - - 219 See index for details. ADVICE TO A YOUNG MAN ABOUT TO BE- COME A SURGEON. The problem of the evolution, education, or if you please of the making, of a surgeon is a ques- tion which has always greatly interested the pro- fession. I am one of those who agree with the view of Osi/EK that the creative, pathfinding, or epoch-making ideas come to all men before they are forty years of age, although some may not pub- lish or elaborate them until they are older. I am therefore of the opinion that the making or education of a surgeon should begin early. I am convinced that a silk purse cannot be made out of a sow's ear and I know that the gold must be in the ore, or no process of refinement can possibly evolve or extract it. I know, however, that some young men with very limited training, often out- strip some of their fellows who have had great scholastic advantages. There must be something 10 GOLDEN RULES OE SURGERY. in these untrained men which schools and lessons and other educational processes could not supply. Exactly what this something may be is very hard to say. My opinion, in a few words, is that the young person must belong to that type which Mr. HadlEy, the President of Yale College, has called a fact-seeker. The young person, male or female, must be one of those whose hands, as well as whose brain has been educated. I may be better understood if I say, — he must be one of those who has learned to use his five senses. His eyes, his sense of feeling, of hearing, of smelling and of tast- ing, must be capable of a development far above the average. He must be able to arrive at correct con- clusions by accurate observation, that is, by using his senses. We have recognized that the highest function of a surgeon is to make a diagnosis. The ability to. treat disease is entirely dependent on the recognition of the pathological condition. The operator will always rank just next to the diag- nostician but can never be considered to stand higher than the diagnostician. It is well and much to be striven after that both functions be combined in one man, but experience has proven that two can be relied upon better than one alone. It is THE EDUCATION OF A SURGEON, 11 wise to have two kinds of talent in all obscure cases. Obscure and dangerous cases tend to make us modest, so that the suggestion of calling con- sultants is more readily accepted. In simple, clear cases, consultations are not only useless but often directly harmful. Besides being a man of educated trained senses, I think the young person taking up the study of surgery should be self-reliant, full of sympathy with mankind and last but not least, should have a love for acquiring scientific truths. In addition to these basic traits every quality of mind which would make an honorable, cultured gentleman would be desirable. It seems to me that an education in a scientific school such as Sheffield or the Boston school of Technology would fit a young man better for the life work of a surgeon than a college course lead- ing to the A. B. degree. At institutions like those mentioned, physics and chemistry are taught, with- out which an understanding of biology and phys- iology is simply impossible. The education of young gentlemen in Amer- ica, will lead to the making of a better class of surgeons than an early education in Continental 12 GOLDEN RULES OF SURGERY. Europe or England, in the fashion prevaiHng there at the present day. At country parties in Europe I have seen young gentlemen absolutely helpless in cases of accident. They could neither saddle a horse nor unhitch a team in an emergency, al- though they were stylish riders and drivers. You must know^ that the European gentleman has his sons and daughters trained in riding, driving, swimming, shooting, etc., by a teacher from whom they receive lessons in these arts. Our American boy learns these accomplishments by hard experi- ence, which after all is the best school. In most cases we learn to shoot, by virtue of disobeying our parents, and so it is with other accomplish- ments of a sporting and athletic character. Our boys are therefore more practical and useful in an emergency and are more resourceful when it comes to using their hands in case of accident or in a surgical operation requiring manual dexterity and a cool, head. Our young man is now ready to enter a medical school and the first year ought to be devoted to anatomy, physiology, embryology and organic chemistry. In the second year he begins pathol- ogy and continues histology both normal and path- THE EDUCATION OE A SURGEON. 13 ological. During these two years nearly "all his time should be spent in the dissecting room and the laboratories. Pathology of course includes bacteriology. Having taught anatomy for eighteen years in various medical colleges, I may be permitted a few remarks about the study of this science. Anatomy is the discipline which teaches the structure of organisms. , Medical men have always looked upon it as an auxiliary science, a sort of handmaid to medicine, because upon it is based the art of surgery. Until recent years our knowledge of anatomy depended upon the dissection of human and other animals. When we look back over the field we are more and more astounded at the enor- mous number of facts we have learned about the structure of the human and other organized bodies by dissection. Until recently our knowledge rested on microscopical and macroscopical dissection. Re- cently the modern science of embryology has given us a more stable and scientific basis for our anatomical work. Suppose you are desirous of in- vestigating the structure or construction of a com- plicated machine, say for instance a man-of-war. Is it not at once clear tp you that you can under- 14 GOLDEN RULES OF SURGERY. stand its structure much better if you watch the building of such an engine of war, than if you tear one to pieces or dissect one? There can be no doubt about the best method to pursue. Watching the development and construction of a complicated machine to its completion will at once give you an understanding of all its parts and functions, where- as the mere dissection or taking apart of one will not give you this understanding, although it will acquaint you with its parts. Remember that anatomy which is learned by memory is easily forgotten and is often useless, but anatomy which you have grasped by your reason and understanding will last forever. For example let us take a question in anatomy: Why does the recurrent laryngeal nerve dip down into the chest forming a long loop around the arch of the aorta on the left and around the subclaviaji artery on the right in order to reach its end in the muscles of the larnyx which govern the voice ? A man who has studied embryology at once answers the self-evident question; an anatomist whose knowledge rests on dissection cannot answer at all. Let me therefore caution you again — do not depend on anatomy which you have committed to mem- THK EDUCATION OF A SURGEON. 15 cry, but learn anatomy by using your sense of un- derstanding and of reason, as well as the sen§e of seeing and feeling. Learn to understand the struc- ture of the body, on which depends your ability to do surgery, by studying its development from the ' ^gg stage to completion. Your knowledge of an- atomy and of physiology must not depend upon what you read in books; it must be founded on observations made by yourself by the use of your senses and the use of instruments of precision. You can have no scientific knowledge as long as you depend upon the authority of books and lec- tures. Science abhors authority. It requires demonstration of facts, it believes nothing upon any one's authority. But very few hours can be given to didactic lectures. Actual work in the laboratories, repeat- ing the fundamental experiments of biology, is •the student's main occupation and these he may vary as much as his inclination to do so, or his genius will prompt. It is not at all excluded that the young student may make important modifica- tions of existing methods, indeed he may make discoveries. He will probably find many facts which are not mentioned in the text-books. These 16 GOLDEN RULES OF SURGERY. he will at first belie"\'e to be discoveries, because he will expect too much froni his text-book. But before long if his work contiaiues on proper lines, and by that I mean continued laboratory work with the aid of a teacher ^vho is an investigator or researcher, he will soon find out that a text- book is a poor, but necessary assistant and ad- viser. He will soon find the text-book a most in- complete and unreliable authority in scientific ex- periment and research. In the second two years the student takes up the practical departments and nearly all his time will be spent in practical courses and in clinics. Again he will consult text-books, but he will have learned that observation at the bedside is his most attractive and most profitable method of study. Attending didactic lectures on surgery and medi- cine he will find a waste of time, and the brighter students will cut these didactic lectures because they learn more at home from a good text-book than from a lecturer. The reason for this may be illustrated by an example. There are doctors who are bright glib talkers, but who are very poor pathologists and only average surgeons, neverthe- less they become professors of surgerj-, in certain THE EDUCATION OF A SURGEON. 17 medical schools. They teach the principles of sur- gery by lecturing before classes to the liking of some of their hearers. No one will pretend that their lectures will compare at all with Senn's beautiful and clear chapters, but all know that the lectures are simply taken from Senn's or some similar book. They are weak, degenerate, and in- complete rehearsals of the text-book. No further argument is needed. The student would gain by studying the text-book and cutting the lectures. The passing of the didactic lecture and of other similar methods of misteaching increases pari passu with the extension of laboratory courses and dem- onstrations. This fact applies to all scientific stud- ies and to the arts and crafts that depend on science. By other similar "methods of misteach- ing" I mean methods of learning by rote, such as rehearsals, quizzes and parrot-like recitations. These methods may help weak brethren to pass examinations, but are really unedifying and do not educate or instruct, nor do they exercise the intel- lect. In the university of the future, there will be but little room for lecturers. Lectures, recitations, etc., will be relegated to the cheap wild and woolly I 8 GOLDEN RULES OE SURGERY. colleges, where eloquence and oratory stand for knowledge based on scientific research. During the last years the student will do best to spend all his time in clinical courses. Hospital clinics, obstetrical, insane, orthopedic, in fact daily attendance jn the wards of all varieties of hospitals must engage most of his working hours. Only a few hours must be reserved for the reviewing of notes by the aid of text-books. The student will now be graduated and then comes the most im- portant step in the making of a surgeon. He must now become attached to the stafif of a hospital or become assistant to a surgeon who has hospital connections, so that he may take part ip the daily exercise of the science and art of surgery. Ex- actly how many years should be thus spent, I cannot say. One, two or three years should suf- fice to turn out a surgeon who is capable and ready to offer his services to the public with a good pros- pect of making a useful and a successful diagnos- tician and operator.* Before closing this short •Whether or not every man who intends to "become a surgeon should do general practice for two or three years, will depend on the kind of hospital experience he may have enjoyed. We will admit that a general practice experience will never hurt a surgeon, but we do not deem it necessary in all cases. THE EDUCATION OE A SURGEON. 19 memorandum on the making or evolution of a sur- geon let me add a few more reflections. I do not believe that any one can become a really good surgeon who does not think of him- self that he can perform a resection of the pylorus, a resection of the three branches of the trigeminus or the extirpation of the Gasserian ganglion, near- ly or quite as well as any other surgeon in the country. Neither do I believe greatness can be achieved in surgery by any one who does not during the first five years of his practice remove some malig- nant growths from the face or neck of an unfor- tunate fellow, which have been pronounced inop- erable by some old and prominent surgeons. It follows that in my opinion surgery is not yet a complete and perfect art. The technique will con- tinue tO' be improved so that we can extend the field of Work still farther and make it still safer than we have it now. Finally let me say that a great surgeon cannot be recognized by the public. They have no way of judging between a good doctor and a quack or between a real surgeon and a mere pretender. The cardinal way- of judging of a surgeon's work is to 20 GOLDEN RULES OE SURGER'i. see it done and to be allowed to see the final results of the operations. A great surgeon will therefore always be willing to invite colleagues, young ones as well as prominent ones, to witness his opera- tions, to watch his after-treatment, and to study his results. An infallible sign of a great surgeon is his willingness not only to show his results, but to teach and demonstrate his methods to students and colleagues from any or all quarters of the globe.* The acquisition of scientific truth for the ben- efit of mankind, is made as easy and free as the air we breathe, by the great universities. Our rich men, by endowing these institutions are doing great deeds for their fellow-men of this and of fu- ture generations. Great surgeons owe it to man- kind to make the art of surgery as accessible and free as is the science. *It is a good plan to see different surgeon? at worlj in their own hospitals. I know of no place that offers better opportunities to learn than Rochester. Minn. I recommend it as a finishing school to all young men ambitious to become good surgeons. Use your eyes and your ears while there; keep your mouth shut and watch. Not only the Mayo brothers will attract your attention, but their whole staff is worthy of careful following. The patholo- gists, the ansesthetists, the assistants, as well as all of the specialists, are carefully trained and selected men who are capable of teaching and dem- onstrating. SCIENTIFIC CONTRIBUTIONS. 21 ON SCIENTIFIC CONTRIBUTIONS TO THE LITERATURE OF MEDICINE AND SURGERY. One of the most effecti\e ways and means of becoming rapidly known as a surgeon among one's colleagues is the publication of contributions on surgical subjects in the contemporary medical press. The effectiveness of such work depends tirst upon the character and value of the commu- nication and secondly upon the kind and quality of the scientific journal that is chosen for the vehi- cle of one's writings. Unless the essay, article, study or the report of interesting cases or of a series of cases, is well written and logically and artistically presented it will tend rather to injure than to advance the young surgeon's progress. It is quite as easy to write oneself down as to write oneself up. 22 GOLDEN RULES OE SURGERY. The choice of the subject is not so important and no advice can be given about that, beyond say- ing that to write about any subject requires the writer to have intimate knowledge and experience by actual observation, and that to write on any subject about which one has only literary or hear- say information, drawn from books, is always sui- cidal, in fact is silly and childish, and of no value beyond that of being an exercise for a schoolboy. A communication of that kind fools no one and only makes a laughing stock of the author. A contribution to a scientific joui-nal should be properly constructed. By way of introduction it should show what is known on the subject up to the time of writing. The writer should accurately give the bibliographical references oh what has been heretofore published about the matter in hand. For this purpose it is not necessary to re- fer to what text-books say about the question be- cause they can hardly ever be considered as depos- itories of scientific communications. They are in nearly all cases merely compilations. You will always refer onl)-^ to original memoirs or mono- graphs, giving the name of the author first, then the subject of his book or article, then the page SCIENTIFIC CONTRIBUTIONS. 23 to which you refer, then the name of the publisher and the year in which the publication occurred. If there has been more than one edition name the one quoted. Let these references follow each other in chronological order and let them be accu- rate. Never quote a book or an article by any, author to which you do not actually refer in your own contribution. After this historical introduction in which you show what was known about the subject before you made your own investigation, you proceed to the main and most important part of your paper. This will consist of a detailed account of your own labors, giving your observations and the methods by which you carried on your researches. Let this part of yo'ur paper be as long or as short as may be necessary to communicate every single fact which you have found — this part will contain the meat of your work. Let it be accurate, absolutely true to nature and let' it be illustrated, if figures or diagrams will add to the clearness of the description or to the lucidity of the demonstration. After having completed your scientific description and after having given your complete findings, the conclusions should follow. 24 GOLDEN RULES OF SURGERY. These must be drawn from the premises or facts as you found them. You should then state in what your research differs from or corroborates the conclusions which were held by scientists in the past. If your work has been successful in ad- vancing our knowledge a step forward you will have the duty and the pleasure of calling attention to it. Finally it will be a gracious act on your part to express thanks to any teacher or fellow who may have rendered you assistance in your re- search. Be sure also to mention the institute or laboratory or hospital in which your work was done. If the work was done in your own labora- tory or in your private practice be sure to state this to have been the case. I desire to impress upon you, that not the mat- ter alone but the manner of its presentation will largely influence its appreciation by the profes- sion. An article or a book which is clumsily writ- ten, though it contain somewhat of scientific truth may fall fiat and be overlooked. An article which adds artistic and literary finish to its scientific nu- cleus will always be sure of attracting its full • quota of notice from the scientific world and will receive very favorable notice from the critics and SCIENTIFIC CONTRIBUTIONS. 25 reviewers. You may be fortunate enough to have your 'paper, book, monograph or whatever form your contribution may have taken, translated into a foreign language or reviewed by contemporary scientific or medical journals. These reviews, or translations, or perhaps quotations, will be gratify- ing to the author exactly in proportion to the standing of the scientist who quotes the work. And if the quotation be made, together with ap- proving and confirming words in the text and by a writer personally unknown to the original con- tributor, the latter may justly be encouraged to further research. Remember that to the artistic and literary merit of the contribution will be due a large part of its success. Therefore don't hurry. In giv- ing the anamnesis of a case 'or a series of cases let' all data be complete. Give facts, let the reader exercise judgment. Do not for instance explain away deaths after hysterectomy or after pyosalpinx or after appendi- citis operations by pneumonia, nephritis or other pathological processes. The pneumonia or neph- ritis would probably not kill the patient if there were no septic infection. Remember that qui 26 GOLDEN RULES OF SURGERY. s' excuse, s' accuse — and that if a patient enters your hospital alive and is carried out dead a few days after an operation he probably died in consequence of the operation. Let it go at that, excuses will only make things worse. You did your duty, you tried to save life, ultra posse nemo obligatur. A few words in regard to the choice of the pub- lication in which to print your work. If the re- search work has been done under a great master or at a great laboratory in a university, or in such a hospital as for instance Johns Hopkins, of course the research will be published in the local bulletin or transactions, and at once will enjoy the entree into the scientific world. It is manifestly impossi- ble to designate by name the most suitable vehicle for a future publication. But I will say this, do not contribute to any weekly, monthly or quarterly publication of which it is clear to every enlightened member of our profession that it is merely a com- mercial enterprise. In order that I may not be misunderstood I say, avoid trade journals or such as are owned and published by pharmaceutical or patent or proprietary medicine houses. It is pos- sible to find a good article in a trade journal, but even if a blind chicken does now and then find a SCIBNTlIfIC CONTRIBUTIONS. 27 grain of wheat, the grain of wheat may be badly tainted or even rotten; because of its putrid or un- s'avory environments. An article in one of these journals, if it recommends some special prepara- tion, will always be regarded with suspicion and its author runs the risk of placing himself in an oblique light, be-he ever so honest. If an article is intended to reach only a limited number, of a special department, of course you will choose a special journal. But if the subject is of more general interest, I am giving good advice in recommending one of the large weeklies. Both the latter and some of the monthlies have been recently much improved in regard to value of sci- entific reports as well as joi editorial work. Amer- ican weeklies and monthlies will never equal the European until contributors are liberally paid for their work, a thing much to be desired by the en- tire medical world. The same is true of profess- ors in medical colleges. These latter will always be of inferior quality until the teachers are paid good living salaries, so that the work of teaching in medical colleges becomes more important than the following of the practice of medicine and sur- gery. Then the professors will have the exalted 28 GOLDEN RUIvES OF SURGERY. scientific standing in our country that they now have in Germany and in France. There is also improvement in this direction noticeable vvrithin the last decade. When oncethe immense wealth of such univer- sities as Chicago and Harvard and the endow- ment of institutes and of laboratories for scientific research, as we see them starting up in Washing- ton and New York begin to show results the United States will soon be at the head of the world in this respect also. Men will come to America, as we in the past have gone to Europe for the best opportu- nities to do original research. This will come to pass during the next twenty-five years and our children will enjoy this American Renaissance of the Twentieth Century. These institutions will then furnish the highest class of archives, quarterlies, monthlies or weekly bulletins, in which to publish the results of our investigations. Before closing this chapter on the subject of scientific contributions to literature, I think some experiences of my own may be instructive and use- ful. My first two publications were embryological researches and were printed in the Morphologisches Jahresbuch of Leipzig and ha\e been quoted by SCIENTIFIC CONTRIBUTIONS. 29 every author who has written a text-book on this subject in any language. This work was done in 1876. I must say that the prompt acceptation of these two memoirs was due to the fact that they emanated from the laboratory of Gegenbaur who together with HuxtEY and HaeckeE was the lead- ing scientific investigator in the field of biology in 1876. After returning to America to practice sur- gery my contributions to its literature have been very tiumerous and I will relate a few of my most curious experiences. Soon after my return I was consulted by a girl of seventeen years about a tumor in her tongue which was rapidly growing and completely filling the mouth. It bulged out upon the back of the tongue as large as a walnut and also bulged the floor of the mouth downwards so as to make a round ball below the chin and above the hyoid bone. I removed it through a median incision. It proved to be a genuine struma or goitre situated entirely within the tongue, extend- ing from the pyramidal process of the thyroid gland to the foramen caecum on the back of the tongue. The literature of surgery, searched very thoroughly by me, spoke of no tumor originating in the thyro- lingual duct. I think indeed that there were few 30 GOLDEN RULES OE SURGERY. if any surgeons then living who would have known what this duct is. I plainly expressed my opinion that this tumor (at least twenty similar ones have been described since) was developed from epi- thelial cells which were left in the track of the thyroid gland as it is developed from the primitive epithelium of the pharynx or head gut. It takes its descent between the two halves of the tongue before they grow completely around it and are joined together to form the tongue. This obser- vation was published in the St. Louis Medical and Surgical Journal. It rested there, nothing was said about the rather interesting and rare tumor for a number of years. About six years after my publi- cation Mr. J. Bland Sutton of London, chief sur- geon of the Chelsea Hospital, in a very clever work on tumors quoted my paper, and agreed with my explanation of the origin of the growth. Since then this peculiar tumor, now called intra-lingual goitre, has been quite frequently seen and written about in all civilized countries. But an American surgeon must be credited with the neat little scien- tific discovery, for which embryological studies made at Heidelberg laid the foundation. I can assure the young man beginning the study of his SCIENTIFIC CONTRIBUTIONS. ol profession that few things will give him as much satisfaction, as to explain or clear up any phenome- non, whether normal or pathological, which has hitherto been unexplained or looked upon as a problem or a curiosity in science. Among my earliest contributions to the art of surgery was a paper entitled ide^ai, cholUcystoTomy — it made a plea for a new method of operation and reported a successful case of gallstones treated and completely cured by the new operation. Mr. Lawson TaiT of Birmingham, England, had just reported a series of successful cases of cholecysto- tomy. His operation strictly followed nature's method of discharging gallstones. He attached the gallbladder to the abdominal wall by sutures, then opened it and evacuated the stones and other contents. The hole was allowed to remain open and was drained until it closed spontaneously by the natural healing process. Nature achieves the same result by means of adhesions between the gallbladder and the abdominal wall, followed by abscess and perforation on the belly wall over the region of the gallbladder. This process leads to the formation of a biliary fistula which often dis- charges for weeks or months or for years. Thus 32 GOLDEN RULES OF SURGERY. Tait's method appeared to me as the natural method of cholecystotomy and the method which I described seemed to me to deserve the name of IDEAL CHOLECYSTOTOMY because it immediately- achieved a restoration to health without the form- ation of a troublesome fistula. I plainly stated the indications for the ideal operation. It can not be performed in every case, in fact it can only be per- formed in carefully selected cases. But where it is indicated it gives ideal results. Kocher in the last edition of his operative surgery speaks of it as a most simple and safe operation! At the end of this paper I drew conclusions, one of which related to the function of the bile. I set up the thesis that the bile must be considered an excretion and that it has little or no value as an aid to digestion, in fact I believed that there was no reliable evidence upon which to base the theory that the bile was of any use to the economy. This conclusion was based upon observations of biliary fistulas. I had seen several of months' and one of over twenty years' duration in which all the bile was dfscharged and the subjects of the fistula in perfect health. SCIENTIFIC CONTRIBUTIONS. 33 This publication was made in the St. Louis Weekly Medical Revieiv about the year 1883. My doctrine went unnoticed in medical literature for about twenty years. Lately I have noticed several voices in Germany practically maintaining the same views about the bile that I published long ago. I am fully convinced of the correctness of my view and believe that it will prevail as soon as the question is pi'operly and carefully investigated by a physiologist or a physiological chemist. That my doctrine had passed unnoticed is probably due to the fact that it was published in a surgical me- moir which was not read by physiologists. It has thus escaped being noticed for years and the lesson which can be drawn from this experience is : Do not hide or bury important physiological findings in medical or surgical contributions. You Can thus see that the selection of the proper medium in which to publish your contributions may be of great importance. My communications to surgical literature num- ber over one hundred, some of the most important being in connection with the subject of appendici- tis, the large majority however being case-reports and reports of operations suggested by me or done 34 GOLDEN RULES OF SURGERY. for the first time by me. If ever anyone should conceive the foolish idea of writing a geographical paper on "the progress of surgery west of the Mississippi river" the records would show that the first operations on the stomach, the extirpation of tumors of the brain, the liver, the kidney, the intestine, gallbladder, etc., were done by me in this territory and also that the first successful oper- ation for gunshot wound of the abdominal viscera was done by me in this territory. There is only one operation which I was the first in the world to do successfully and that was the Caesarean sec- tion in a case of placenta praevia. I still believe that this operation has a future under certain cir- cumstances, although I am aware that many ob- stetricians are not in favor of it. And still, I will say that having to choose betv^een a young well- trained surgeon and an old obstetrician to deliver a woman with central placenta praevia, I would have the young trained surgeon do the classical Caesarean section in every instance. It must be said here that soon after my arrival in St. Louis in 1877, the ablest and most useful and busiest sur- geon, John T. Hodgen, told me that he had done sixteen laparotomies and said he, pointing north- SCIENTIFIC CONTRIBUTIONS. 35 ward, "I have fifteen tombstones to show for them." Another surgeon [perhaps the next in prominence] in Missouri, told me that laparotomies could not be done successfully in the Mississippi valley, as he believed climatic conditions to be un- favorable. You will understand that in those times the technique of antisepsis was only poorly under- stood and asepsis was unknown. I was among the first to adopt and teach asepsis and wrote a paper on THE BEST METHOD OF PRACTICAL ANTISEPSIS AND ASEPSIS, which did much to popularize the method in the United States. We may assume that at the present day no surgical operation is done without an attempt to be as aseptic as is possible under the surrounding conditions. The time is not far away when no premeditated operation will be performed except in a properly equipped operating room. In fact, I think this rule is now generally observed where such a place is not too distant or inaccessible. Operating rooms which can be made clean, by sterilization in some of its forms, are springing up even in small country towns. There are no more doubting Thomases, the doctrine of surgical clean- liness is universal, in fact there are no dissenters. Thrice happy the profession of which it can be 36 GOLDEN RULES OF SURGERY. said : it is united, at least upon this the most im- portant of its foundations. The modern edifice of surgical art rests solidly on this impregnable sci- entific base. SCIENCE AND SURGERY. 37 SCIENCE AND SURGERY. About ten years 'ago, a new chancellor was called to a western university and after residing in the city for a few months, during which time the reorganization of the medical department kept him busy, he publicly announced that many of the wes- tern physicians did not know what science meant. This statement caused discussion and some ill-feel- ing among physicians, but there is no doubt that the chancellor was right. In order to give medical students and physicians a clear idea of the meaning of science the following th&ughts on the subject may be here expressed. Definitions of science found in most dictionaries are: "Science is knowledge" or "science is clas- sified knowledge."* While these definitions are per- *In this connection permit me to recommend to all physicians who desire to rank above the common herd, the study, yes, the intense and diligent consideration of the small volume by Herbert Spencer called "First Principles." It is the best introduction to science that I know of and can be mastered by any one having the qualifications necessary to become a useful surgeon. 38 GOLDEN RULES OE SURGERY. haps correct, they do not give a complete idea of what the term science means or of its scope. Science is not only the grandest and most im- portant thing on earth, but it deserves our rever- ence and culture more than any god that mankind has ever worshipped or any idol deified in the past. A better definition than the two given is' as follows : Science is the knowledge of the lavvs which govern this universe. Science is still very incomplete because we do not know all the rules upon which nature, or if you like a plain English word better, upon which the world works. In fact we know but a small part of the rules or laws of nature, but we are learning more of them as science grows. Science is truth, anything which is proven untrue can not be scien- tific. An author or a text-book may make certain statements, which are supposed to be true. The author of the text-book believes them to be true, but that does not make them true. Science is absolutely the opposite of belief, it takes nothing for true on anyone's authority or statement. It requires proof by demonstration, and the proof and demonstration of a statement must be open and possible to anyone sufficiently skilled and edu- SCIENCE AND SURGERY. 39 cated to repeat the experiment or demonstration upon .which the statement is based. When this has often been done and the demonstration is found flawless by different men independently of each other, then a statement or a finding or a dis- covery becomes a scientific fact. It does not then rest upon anyone's authority, but we say it is a fact scientifically established. It is clear that science is unfinished as a whole, although some minor fields are pretty well worked up. It is the opinion of scientific thinkers that science never can be completed so that no laws or rules upon which the universe works will be un- known. We may rejoice that this is true, because such a condition would put an end to scientific in- vestigation. Research, and in fact mental effort of all kinds, would necessarily cease. On the other hand, if there were nothing left for belief and faith, if there were nothing left of the unknowable, there would be no room for religions or creeds. Such a condition will never come about, therefore it is idle to waste time on its consideration. If the definition of science which I have given above is correct, then of course science is not only the most sublime thing, but also of the utmost 40 GOLDEN RULES OE SURGERY. practical importance and use to mankind. It is the only thing which can possibly lead to an under- standing and to an explanation of the phenomena which we call life. Our hope of ever knowing ex- actly what life is and how it was developed on this planet, lies in science. There is one other point I wish to raise in this connection. A collector of beetles or butterflies may be a scientific man. The mere collecting of specimens and classifying them does not make him so. At best we may consider him a useful helper who is gathering valuable material upon which some scientific researcher may base scientific ob- servations and reflections, which may lead to the discovery of an important law of nature or supply a missing link somewhere in the chain of scientific knowledge. Thus we see that in science there may be two kinds of laborers of unequal .value. The one col- lects facts, the other utilizes these facts, classified or not, in order to base upon them the laws and rules of nature. Both kinds of work deserve our help and our approval, though the latter receives our admiration in the higher degree, because it SCIENCE AND SURGERY. 41 requires the higher intelligence and reasoning power. Just as we recognize that our only hope of ever knowing the laws of life and rules upon which it works rest on science, so do we recognize that medicine and surgery rest on science. The solid foundation of surgery is science, and our only re- gret always has been that the connection between practical surgery and exact science is as yet imper- fect and indeed surgery is often based on unstable, inconstant and variable observations and data. If the truth must be told the practice of medicine and in a still greater degree the practice of surgery are arts. These vocations while seeking for firm scien- tific foundation are far from having attained this object, at the present time. We know that we are becoming more and more successful in the preven- tion and cure of disease, as we become better ac- quainted with the laws of nature. Our hope of still further advance rests upon the progress of science and as science discloses more of the laws and rules of nature we shall become more scientific physicians and surgeons and our fight against dis- ease will become more and more successful. Remember that science is truth. Much of your 42 GOLDEN RULES OE SURGERY. life should be therefore devoted to the study of science. Remember that belief and superstition are the opposites of science and tend to keep mankind in darkness. Science is light and truth. All science is the work of man, and it has been developed by the brain functions of man. The cul- tivation and expansion of the field of science is man's highest and noblest function. Let us re- member for instance that the study of the most universal and highest questions and problems of humanity is Ethics, which also comes under the head of science. The clearest work on Ethics* is by Herbert Spencer. Remember then that the pur- suit of scientific work is man's noblest occupation. Scientific workers more than all others deserve our sympathy and our aid. Let us accord to them honors and reward's without stint. *The Data of Ethics. BUIU)ING UP A PRACTICE. 43 "Else if you would be a man, speak what you think to-day in words as hard as cannon balls, and to-morrow speak what to-morrow thinks in hard words again, though it contradict everything you said to-day." — Ralph Waldo Emerson. ON WAYS AND MEANS OF BUILDING UP A PRACTICE. This subject is immense and a large book could be written on the many details which may influence the career of a physician or surgeon. I can only give the general principles, as in fact that is all that this little work sets out to do upon any of the subjects treated, the author being firmly convinced of the truth of the motto Principiis obsta! Soon after entering the practice, the question of joining a medical society will arise and the only advice that can be given is to join. If there are several to choose between, as there always will be 44 GOI,DEN RUIvES OF SURGERY. in large cities, choose the one which is conducted on the broadest Hnes, the least exclusive; it will most likely also be the most scientific. Be sure to avoid societies which are conducted on the plan of debating clubs, where the members are asked to write papers on subjects selected by a committee for discussion, sometimes called symposiums. It is quite possible that meetings of this kind may be instructive to the beginner but it is rare indeed that a point new to science will be brought out. As a rule the men furnishing the parts of the sym- posium will read compilations from the available literature and at best furnish second-hand inform- ation selected by them from text-books or from so-called original articles in the journals. You will see that an evening spent at this kind of a gather- ing scarcely has much to entice a man of scientific bent of mind, because he has learned while at the university to go to the sources for scientific inform- ation and to avoid hearsay evidence. If there be no medical society imbued with scientific spirit in the city where you live, you will soon learn to avoid the meetings, especially if they should prove to be devoted to medical politics of a more or less personal character. The really good men often BUILDING UP A PRACTICE. 45 shine by their absence from the regular sessions. This state of affairs will improve when societies will only listen to original communications. About joining other social organizations, secret or otherwise, with a view to gaining practice, I merely say,. don't. The legitimate way to gain practice is by faith- ful performance of duty to your patients and by the results which you achieve by your operations and treatment. Begin by treating the servants and end by treating the mistress. If your work is painstak- ing and you take interest in it, your practice must grow because nature has wisely arranged matters so that of one hundred patients who call upon a physician about ninety-five would recover even if left without treatment of any kind. It is thus ap- parent that you will be successful in the vast ma- jority of cases, and your grateful patients will do the rest in order to increase your practice. It is well to know this fact because it will give the be- ginner courage and confidence and prevent him from resorting to radical and dangerous measures in simple cases. An appreciation of this fact alone, will show the beginner that his plain duty lies in the conscientious examination and diagnosis of all 46 GOtDEN RULES OE SURGERY. cases, so that he will be sure to separate the dan- gerous from the simple ones. This he will find an occupation that will fully tax his scientific attain- ments. In this connection it may be well to say a few words on the relation between the legal and the medical professions. These come in contact most frequently on the occasion of damage suits against corporations, most often against railroad compa- nies and other common carriers, through expert testimony either for the plaintiff or the defendant. Here let me say for the solace and encouragement of the young medical man that it will be found that on medical or surgical topics the most brilliant and able lawyer will still be only a layman as compared to even a very mediocre surgeon. A knowledge of this fact will allay the great nervousness of young surgeons appearing in court, but let them not for- get that the reverse is true should they venture upon the field of law. Another occasion upon which these two pro- fessions will come together is the malpractice suits brought against members of our profession. These are in most cases attempts to get money from a physician with little or no justification in BuiivDiNG UP A practice;. 47 • fact. It stands to reason that no sane surgeon would intentionally injure a patient. Therefore a presumption of bad faith lies against the plaintiff in these cases. Furthermore, recognizing the falli- bility of all men, even the best, the law does not re- quire more than ordinary skill and care on the part of the surgeon. From the fact that the result of any injury or operation can not be guaranteed by the surgeon, in all cases, and that our knowledge is incomplete because largely empirical and not al- ways based on science, it becomes our plain duty to assist fellow-surgeons who may be made de- fendants in suits for damages. In testifying before juries in these cases let me suggest one bit of ad- vice. On all such occasions make yourself under- stood by discarding technical terms. For instance, do not speak of fracture when you mean a broken bone, nor of tibia when the English word shin-bone will convey your exact meaning. Many case^ are lost because the minds of the jury are befuddled by the expert witnesses who use terms that are unin- telligible to the jury. In a damage suit tried re- cently one of the experts for the defendant dis- qualified himself from ever testifying in behalf of another fellow-surgeon and also vitiated his testi- 48 GOLDEN RULES OF SURGERY. • mony in the case at bar in which a surgeon was sued for malpractice. It was a case of crushed knee with fracture of the femur near the joint, dirt from the street having entered the wound in which the surgeon made a primary resection resulting in a flail joint. The suit was for $20,000. The plain- tiff claimed that the operation of resection was too radical and a more conservative method should have been followed. During his cross-examination the expert said that he would under no circum- stances testify against a brother physician. This, of course, was going too far in a good cause, and I want to call attention to the great danger of over zealousness on the witness stand, because it defeats its own object, as it did in this case. The record will forever preclude this surgeon from aiding a brother who may be held up by a designing and unscrupu- lous plaintiff. Therefore be calm and do not over- shoqt the mark. In recent years insurance com- panies against possible damages from malpractice suits have sprung up in the United States and I am so favorably impressed with them that I most cordially recommetid them to all colleagues, though I never had the advertisement of being sued for malpractice. BUILDING UP A PRACTICi;. -49 Finally, avoid frictions and jealousies with col- leagues, keep out of cliques, remember that strong men can stand alone, weak ones must lean on each other. And if you are persecuted by jealous rivals, cheer up ! Men do not combine against insignifi- cant foes, or train parks of artillery against fleas. "The most clubs are found under the best apple trees," Abraham Lincoln told Mr. Seaward on a memorable occasion. So, I say to you, keep right on with your work. If it is good work, lies will not retard your success. 50 GOIvDBN RULES OF SURGERY. ABOUT FEES. Surgical services have no fixed cost; they are without value in that they are invaluable. As a general proposition it is true that large fees have a tendency to elevate the profession in the eyes of the business w^orld. This matter of fees has noth- ing whatever to do with the scientific attainments of a physician or surgeon. Recently the medical press has editorially and otherwise given much space to the subject of the division of fees or to the paying of percentage or commission to men who refer or bring cases to eminent colleagues and specialists. A maudlin, and ill-advised stand has been taken by some in favor of the practice ; the argu- ment being that the poor general practitioner is underpaid for his work, gets a mere pittance from his patients, and often nothing at all. This argu- ' ABOUT FEES. 51 ment falls because of the fact that no man is obliged to render valuable services free of charge. If he does not charge and collect, the presumption is that the services in his ovi^n estimation are cheap or without value, always supposing the patient able to pay. Where patients and their friends and relatives are unable to pay, charity should always be exer- cised to the utmost by our profession. Where the ability to pay exists good fees should be insisted upon. The fee should be in proportion to the service rendered and its value to the patient. The practice of paying, commissions is vile, mean, dishonest. Not only the man who receives the commission is degraded but also the man who grants it. I favor a definite understanding between sur- geon and patient before the services are rendered. Beware of becpming a commis 'voyageur or drummer. Don't often attend little county or dis- trict societies — let the country doctors attend the big meetings. It will be more profitable to them. 52 goldi;n rules of surgery. "The objects I have had in view are briefly these — to promote the increase of natural knowledge and forward the appli- cation of scientific method to all problems of life — in the conviction that there is no alleviation for the sufferings of mankind except veracity of thought and action and the resolute facing of the world as it is when the garment of make-believe by which pious hands have hidden its uglier features is stripped off." — Thos. H. Huxley. OFF WITH THE CLOAK OF SUPERSTITION WHICH STILL CLINGS TO THE SHOULDERS OF THE PROFESSION! To see sumptuous edifice upon sumptuous edi- fice going up to new cults which cater to the eter- nal craving for the mystic that lies in the heart of man, one might suppose that the tide of supersti- tion was rising. What does the progress of science, what do the researches made in all exact branches OFF WITH The cloak OF SUPERSTITION. 53 count for, we ask ourselves, when thousands flock to the abodes of fakirs, charlatans, divine healers and others of that ilk, to whom anatomy, physi- ology, and elementary disciplines of medicine are a book sealed with seven seals ; not to speak of diagnosis and the* difficult art of surgery which can only be acquired by men particularly gifted in the first place and most particularly trained in the second. I am afraid that even our own profession does not do all it could to help "ecraser I'infmne" as that enlightened Eighteenth Century philosopher, the astute and persistent enemy of supersition, Voltaire, phrased it. Most of his letters to Freder- ick THE Great of Prussia, and there exists a volum- inous correspondence between the two, ended with the war cry, "Bcrasez I'infmne" (Crush the infam- ous), with which adjective he designated super- stition, or often by way of abbreviation with only the cabbalistic-looking word, "Ecrlinf," made up of the first syllable of ecrases and the first of I'infame. Voltaire, dead more than a hundred years, understood better than many of our own latter-day practitioners of medicine that the only way to wipe out superstition is through enlighten- 54 GOLDEN RULES OE SURGERY. ing the people. If he could this moment be cited back from the dead and personally conducted through the United States with its many inventions to make things go, such as steam transportation and steam navigation, electric lighting, telephones, steel-ribbed sky-scrapers and whatever other ap- purtenances human ingenuity applied to the con- quest of nature has devised, he might be for an in- stant astounded. But would not a sardonic smile play about his. thin expressive lips as soon as he dis- covered the vogue of Mrs. Eddy's medical religion? And when he beheld the temples erected to this new revelation, "Ecrlinf !" he would mutter and hie himself back into the shadowy region whence he came, convinced that his work was far from com- pleted, though seemingly a race of giants had been on earth since his demise, which had arrayed the old forces of nature and new ones hardly dreamed of in his time, to be their slaves and do their bid- ding. I am afraid the medical profession is not united in spreading enlightenment and crushing the hydra-headed serpent of superstition. It is so diffi- cult to make earnest and persistent researches, deep and long-continued studies in science, it is so OFF WITH THE CLOAK OF SUPERSTITION. o5 easy to invent a plausible and high-sounding theory about the mysterious workings of nature. It is so difficult and a little depressing to acknowledge that there is much as yet unexplained and inexplicable about the laws of disease and health, it is so easy to make large and sweeping statements and claims which are not susc*eptible of proof or disproof by the untaught laity. There is, moreover, even among the well-educated public a marked disposition to exaggerate the powers of the diagnostician, the surgeon and even the plain practitioner, to invest him with a power and knowledge that savors of the supernatural. Many a heart is not stout enough and honest enough to resist the blandishments of vanity, the whisperings of self-interest to trade upon the stupidity of the public which fairly clam- ors to be deceived. One of the greatest feats of understanding ever accomplished by human intellect is the separation of the knowable from the unknowable. It is clear to all men that if'a thing is unknowable, a question unanswerable, it is a waste of time to occupy one- self with it. Our energies and the time allotted us on earth would better be put to a wiser use. Kant and various German philosophers first elucidated 56 GOI^DEN RULES OP SURGERY. this question of the knowable and unknowable. But you of the English tongue will do best by reading Herbert Spencer's clear and convincing exposition of the bounds of human thought. The question of the immortality of the soul is an in- stance of the unknowable. It is and will always be a matter of faith and not of science and has nothing whatever to do with a man's ability and achieve- ments in an exact science. I would therefore counsel you to avoid discussion of such subjects. It is worse than useless, may make you enemies, at any rate it can in no wise profit you. It is the province of the clergyman to guide the public in matters of belief. To him you may leave the spiritual welfare of mankind. To him also may be left the attitude and the apparel of the Reverend and the Most Reverend, which is of a piece and in keeping with his assumed knowledge of the un- knowable. You who concern yourselves with the knowable have no business to bear yourselves or clothe yourselves with any mental or physical garb which would remind your fellow-citizens of the time when priest and physician were combined in one and the same individual. The long beard which was formerly an attribute of the medical OFF WITH THE CLOAK OF SUPERSTITION. 57 man, thanks to antiseptics has gone out of fashion, but some of the older men of our profession still cling to the long frock-coat and tall hat, as exter- nal signs of their calling. I advise young men not to resort to any external expression of the dignity of their profession. The dignity lies in character, in the conscientiousness, ability and success with which a man handles his cases, not in any trick of the voice, gravity of the countenance, bearing of the body — or meaner still in the garb assumed. Leave all such affectations, accessories and stage- properties to the- quack, the mountebank and the impostor. They are reminders, to be shunned and abhorred, of the time when the priest-physician was inevitably also a charlatan and hypocrite. To Josh Billings the translation of this sentiment into the breezy and unabashed speech of our wide and free and glorious West is attributed. "Dignity," he is credited with saying, "is no more a sign of wisdom than a paper collar is of a clean shirt." Therefore, off with the cloak, whether it be as- sumed to indicate dignity or to hide ignorance. It is a hollow pretense, a husk likely to be empty of anything but arrogance and hypocrisy. Cast it aside as unworthy of an honest vocation. None 58 GOLDEN RULES OF SURGERY. have a better right to walk upright and look men straight in the face than those of our profession. But let us be rooted in science, and based on noth- ing but science. We must disdain to be shrouded in mystery, scorn to let the ignorant impute to us supernatural attributes. Our vocation is the most honorable and the most beneficial to mankind, so long as we keep it free from the pretense to extra- ordinary powers. We need no veil to hide mystic rites, we should wear no ample cloak to drape our forms with dignity as did those augurs of old, of whom it is told that they stuck their tongues in their cheeks as they passed each other in the street in mockery of the ignorant who revered their sup- posed occult powers and imputed relations to the supernatural. Down with the cloak and up with the banner of science which invites the light, ever more and stronger light upon our labors, that all may see and understand what we can do and what to us is impossible I GENERAL CONSIDERATIONS. 59 GOLDEN RULES OF SURGERY. GENERAL CONSIDERATIONS. Asepsis is the first essential condition of suc- cessful surgery; a close second is Rest. Remember that under the influence of rest re- generation and repair of diseased or injured tis- sues takes place most rapidly and is free from pain. Asepsis and Rest are the two conditions under- lying the healing process. The art of surgery con- sists mainly in the application of these two funda- mental principles in the most appropriate manner to special cases. By their faultless application so- called inflammation is avoided. The most successful surgeon is he who can ap- ply this rule effectively in his practice during and after his operations. It is self-evident that without asepsis there can be no rest. There are two kinds of rest — mechanical and physiological. 60 GOLDEN RULES OF SURGERY. The application of mechanical rest is a matter of skill and experience and depends largely upon the personal ingenuity of the surgeon. The most important form of physiological* un- rest is caused by the entrance of infectious material into the tissues. It is the form of unrest we try to avoid by asepsis. It was known as inflamma- tion long before its cause was discovered to be in- fection. This form of unrest is quickly followed by pain, swelling, fever, etc., whereas the lack of mechani- cal rest is not usually followed by these symptoms until it also produces a condition which I have called tissue-unrest. There is apparently a dif- ference then between tissue-unrest produced by infection and tissue-unrest produced by mechanical causes. If I may be permitted to guess what the diflference is, I will say that mechanical insults do not cause fever unless they cause necrosis of tis- sue, perhaps only the death of a limited portion of tissue which being absorbed causes some fever and pain. See page 137. *The proper term would be patholo^cal-unrest. but the word that fully expresses my meaning if; the new word tissue-unregt. See "Away with In- flammation, etc.." page 138. GENERAIv CONSIDERATIONS. 61 For example in a simple fracture of the arm there can be no infection, because there is no les- ion of the skin. There is pain until mechanical rest is given to the injured parts. There is pain until both kinds of rest are given to the injured parts by reduction, and a proper splint or bandage is applied to maintain it. In another case, for instance in a carbuncle or anthrax-pustule, where septic material has found entry into the tissues, there will be pain until by an incision or by pointing the noxious matter is discharged. Thus we see that a knife may be THE direct means OE GIVING REST. The surgeon who has his asepsis all right will find his time most usefully occupied in devising ways and means of achieving rest to the tissues that have been disturbed by his operations. He will find himself handling the tissues with the ut- most care and tenderness of touch, so as to avoid mechanical disturbance and irritation. He will be- come more gentle in his operative manipulations, as he realizes the dangers of creating increased pain by rough handling of tissues. One of the main objects of the dressings we put on wounds is to give the parts as much rest as possible. 62 GOI,0EN RULES OF SURGERY. That pain is absent when we can give rest to diseased parts and, that pain can be reHeved by- rest, are two of the most important rules of prac- tice a surgeon must learn. I hope that no one will so misunderstand the golden rules about the influence of rest in regenera- tion and healing of diseased and injured tissue as to give opium or morphine to produce rest. That would be to change the most important and ftmdamental rule of surgery into the most dan- gerous and harmful practice. Rest secured by means of poison injected into the human organism is apt to do more harm than good. I am convinced that the administration of such drugs as belladonna, cocaine, morphine, strychnine, veratrum, digitalis and many oth- er poisons to human beings, by even our most highly educated physicians, is wrong. We know but little of their real effects upon the healthy ani- mal. How much less do we know of their force and effect on the weakened organism of our pa- tients? I am of the opinion that the physician who GENERAI. CONSIDERATIONS. 63 uses these drugs upon his patients overestimates his own knowledge of the action of drugs, and nearly always has been misguided by his blind trust in the text-books on materia medica. I wish to go- on record as being opposed to the general use of drugs in the treatment of disease. The idea that a doctor's main business is to write prescriptions must be abolished among the public. The scientific physicicui cannot but feel the deep degradation of being asked for a prescription with- out first having a chance to make an examination and diagnosis. The public must be trained to pay for the latter and not for the former. If we reach this appreciation of our work from the public, as many of us have done, there will be but little left for the prescription doctor and the ignorant quack to prey upon. Remember to talk and to act in favor of the public schools and state universities whenever an opportunity presents itself. Do the same in favor of the taxation of churches and all kinds of property held in their name, though they be,hospitals. If this is not done soon these institutions held by the dead hand (la main morte) will be so rich by escaping 64 GOIvDEN RULES OP SURGERY. the taxes, that they will wield more power than the trusts do now. Any good actuary or banker can figure out this problem for you. The reason why some American surgeons ex- cel European surgeons, who would seem to have the better opportunities for study is because their knowledge is autoptical. The European bases his knowledge and judgment largely on autopsies. During the past year the Mayo brothers removed o'ne thousand and twenty-one appendices from liv- ing patients. Incidentally let me remark that eight of this number died. I cite this experience as an instance of autoptical pathological study. It is my opinion that in conjunction with the microscopical examination of the appendices the autoptical knowledge and judgment of the process under consideration will be much more valuable than the autopsical knowledge of the Germans, if I. may be permitted to coin a word. The same is true of stomach, gallbladder and many other le- sions that are treated surgically in our day. Therefore let young men miss no opportunity to see operations and to examine the diseased tis- sues or organs. The autoptical view will always be more instructive to the young surgeon than the autopsical. gi^neral rules oe practice. 65 SOME GENERAL RULES OF PRACTICE. Beware of diagnosing any disease of which you have recently read, or have lately seen or heard of. Amputation of a finger or toe is minor surgery, of the thigh is major. Who can drawr the dividing line? Never confine old people to bed for long [on account of the tendency to fatty and dilated heart and hypostatic congestion of the lungs]. Never use a hypodermic syringe in a patient in the secondary stage of syphilis, or if you do,- re- member thoroughly to ascepticise it after use. Never permit a wet-nurse to be employed with- out examining into her history and state of health. 66 GOLDEN RULES OE SURGERY. Never permit a healthy wet-nurse to suckle a syphilitic child, or a child of syphilitic parents. Never be hasty in suspecting "malingering" in any disease, certainly never in head injuries. Remember that if a man has been taking a quart of whiskey per day for years, and you take it away froAi him suddenly during an acute attack of fever or pneumonia, he will probably die. Never neglect to bandage carefully the entire limb, if you have encircled it at any one point to keep up pressure upon a wound. In the broken down, avoid cathartics, depriva- tion of nourishment, and loss of blood by incision. Remember that drunkards, children and pa- tients with jaundice or splenic disease, bear loss of blood very badly. Be careful of opium in delirium tremens when the. pupils are contracted. Never examine any female per vaginam under any circumstances without having first obtained her consent, nor without the presence of one or more reliable witnesses. GENERAL RuivEs 0? practice;. ^7 Never examine any female prisoner per vagi- nam without her consent, without cautioning her that the examination will be taken down in evi- dence, and without a female companion being present. Remember that in all organic lesions of any part of the body which the patient can himself see or feel there is always a psychical element. This feature of the case may require treatment. The removal of the growth or deformity is the best and the most radical cure. But when for some reason surgical operation is impossible, much relief can be given by suggestion and persuasion carried out by a clever physician. In many cases a change of en- vironment, by travel, or weeks spent in a sanita- rium or an institution, aided by massage, gymnas- tics or some similar therapeutic method may be of great benefit. Remember that in most aseptic operations that we can do, several thousand bacteria will get into the wound. These will be nicely eliminated or made harmless if the tissues have been gently handled by the operator and are healthy. Rubber gloves are of use if the operator must 68 GOI.DEN RULES OF SURGERY. do an aseptic operation after a septic one. They are not the boon that we expected them to be. I have nearly abandoned them after many trials. In my case so much fluid or sweat accumulates in them in a short time that a puncture will let out a half dram or more of fluid containing many bac- teria, especially if I have been obliged to use much force in tying ligatures. There are other objections to gloves. Death following a minor operation, in which it was least expected, is among the most horrible ac- cidents that can befall a surgeon. These deaths are due to septic infection in about ninety-nine cases out of one hundred. They follow an infec- tion, and death usually ensues in from two to thirty days after the operation. In these cases the error in the aseptic arrangements nearly always escapes detection. It is found irnpossible to locate a fault or mistake with any of the nurses, assistants or with the chief operator. The same staff may have done several successful operations of much greater importance in the same room, on the same day. In these cases we are reminded that our antiseptic precautions, or our asepsis, is not yet infallible or reliable. When a minor operatibn, such as for in- stance an operation for piles, a perineorrhaphy, or GENERAI, RULES OF PRACTICE. 69 a cosmetic operation upon the face, is followed by erysipelas or some other form of sepsis and ends in death, the physician and surgeon are in a most lamentable position. The best plan in this situation is to admit that the cause or point of entrance of the septic poison is unknown and to inform the rel- atives and friends that deaths of this kind are very rare, but unavoidable. I do not think that acci- dents of this kind occur more frequently than fa- talities during anaesthesia and they are growing more and more rare as our technique is made more perfect. (See Anaesthetics, page 75.) The policy of charging these deaths to heart dis- ease or to some obscure form of nerve disturbance is a bad one and should receive the quietus that we have put upon other forms of deception which were formerly sanctioned, because of our lack of scientific pathology. Nothing but the most sincere sympathy ought to be extended to a surgeon to whom this kind of an accident happens. No kind of blame can lie against the hospital or the surgeon to whom this accident happens during a long and successful career. On the other hand, punishment can not' be too severely visited upon an institution or a man whose work shows a regular, long contin- 70 GOLDEN RULES OP SURGERY. ued death-rate which is much above the usual av- erage. Under the protecting aegis of antisepsis and asepsis, fools rush in with seeming impunity — but only with seeming impunity I say — and operate where sages would hesitate. In the past thirty years I have observed hospit- als, sanitariums and similar institutions, and their surgeons come and go. Those whose work is followed constantly by a high mortality never last very long. Such insti- tutes very soon go into liquidation ; bad surgeons lose their practice or retire to some less strenuous department of medicine or withdraw from the pro- fession entirely.* The fact is that surgery unless successful, loses its charm^ and unsuccessful op- erators abandon the field for the relief of their own conscience which will not be quiet until they have either improved their surgical methods, or failing in that, have given up the practice of surgery. There is a vestige of truth in the old saying that surgeons are born, not made — those that are born *A very salutary effect is exercised on bad or unsuccessful operators and their hospitals by the nurses and hospital employees. These latter soon notice an abnormally high mortality following the work of some men as compared to that of others, and this truth will come out. GENERAL RULES OE PRACTICE. 71 with the proper instincts last longest, while those that come into the fold at the eleventh hour rarely seem to grow warm and enthusiastic in the work. Those also who enter the profession with an eye to the main chance, whose first object is to make money out of surgery, seem to be easily diverted into other lines of work and are not usually among the most successful. An enthusiasm which will lead the young surgeon to perform the most dififi- cult and dangerous operations-free of charge seems essential in the character that goes to make a great surgeon. Another thing that seems to character- ize all great and good surgeons is their delight in teaching young men the art of surgery so that they may leave behind them a number of pupils or as- sistants to whom they can point with satisfaction as to their spiritual progeny. If this should lead, as it sometimes does, notably in the cases of v. Langenbeck and Billroth, to a general recognition of their pupils as the leading surgeons of their generation, the ambition and the glory of such teachers of surgery will have reached the summit. There is great danger of overlooking the hu- man or philanth-ropic side of a case in the enthu- 72 GOLDEN RULES OE SURGERY. siasm which scientific research arouses in a student of biology. This science, being the basis of modern medicine, is so interesting and such an enticing field for research that to an intense worker a case .may appear to be merely an object upon which to make scientific observations. Beware of this error and remember that to a patient there is but one object in the practice of medicine, and that is to make him well, to cure his ills. Remember the difference between a case and a patient. Remember to treat the patient as well as his disease. The scientific study and diagnosis oe a case is ON^ thing, the treatment of a patient another. Both functions are demanded of a physician, and the ability to fill them both well when combined in one man has made the great masters in our pro- fession. I do not desire to be understood as exacting all scientific requirements of one man, in our times. Let the case be examined and diagnosed scientifi- cally by expert specialists. Then let the surgeon take the case and operate. MINOR SURGERY. 73 CAN MINOR SURGERY BE DONE IN THE OFFICE? There is no doubt that many surgeons are do- ing minor surgery in their offices. Nothing can be said against this practice if the office is as well equipped for the purpose as is a modern operating room in a hospital, except that the patient will always be subject to the dangers of a transporta- tion to his home. If these dangers seem to be a negligeahle quantity there can be but little objec- tion. And still for all but certain specialists the practice is not to be recommended. I think that such operations as currettement or the ablation of haemorrhoids or the dilatation of urethral strictures should be done under anaesthesia and in a hospital and neither at the home of the patient nor at the surgeon's office. The dangers and accidents which may follow an anaesthesia, either local or general, should not be incurred except at a hospital. Be- 74 GOLDEN RULES OE SURGERY. sides, I' am sure that an office can hardly be sur- rounded by all aseptic precautions as securely as an operating room in a hospital. Another reason for condemning office operations is the fact that the failure or success of office operations will de- pend upon the preparation previous to the opera- tion, which is always necessary; and this can be given much more fittingly in a hospital than else- where. Another weighty argument against office operations is that we never know exactly what pa- tients will sufifer from shock after minor operations, but we do know that the treatment of this condi- tion can become very protracted and may require the most painstaking attention, severely taxing the trained attendants of a well equipped hospital in some cases. Therefore I can not advise the office treatment of minor surgical cases, in other words, I do not favor the performance of operations re- quiring anaesthesia in the office. The after-treat- ment and the changing of dressings in which anaes- thesia is not required may be done in a well fur- nished office, although even for this purpose the dressing room of a hospital is the safest and the most preferable place. ANAESTHETICS. 75 ANAESTHETICS. Never administer an anaesthetic except in the presence of a third person, or allow it to be ad- ministered in your own house. Remember to have all false teeth removed, to secure an empty stom- ach, and a horrzontal position, to release all tight clothing, and to use an absolutely pure drug. The urine, heart and lungs should be examined the day before the operation, by the anaesthetist. Remember that sudden failure of respiration sometimes occurs in cases needing tracheotomy. Therefore, give as little of the anaesthetic as possi- ble — do what is indicated to supply the air or oxy- gen which is wanted. Never forget that while enough of the anaes- thetic should be given to ensure complete insensi- bility before the surgeon commences and while he is operating, care should be taken that the patient 76 GOLDEN RULES OE SURGERY. has no more of the anaesthetic than is absolutely needed. This rule also applies to subcutaneous or intraspinal injection of cocaine. There are deaths reported from intra-urethral injection of small doses of cocaine. Never forget that deaths from anaesthetics are most frequent in operations for trivial troubles. I am one of those who believe that fright greatly increases the danger. Deaths during anaesthesia are unavoidable. Fortunately they are very rare. I have made a most careful analysis of all existing statistics and I think that the mortality of anaesthesia of all kinds for surgical purposes rs in round numbers 1 in 4000. WARNINGS AND CAUTIONS. 77 WARNINGS AND CAUTIONS. Remember never to make promises of any kind, and particularly as to the result and the exact length of time it will require to get a cure, because a wound may suppurate in spite of all our precau- tions. Never forget to warn your patient that a Colles' fracture and other bone or joint injuries, even when treated with the greatest care, leave some deformity. Never forget to warn a patient with fracture of the patella, that the fragments tend to separate. Always warn your patient that there may be loss of power of deltoid after dislocation of shoul- der when much pain has been experienced [pain is the evidence that the nerves have been pressed upon, or greatly stretched]. 78 GOLDEN RULES OF SURGERY. Always warn the patient or his friends of the possibility of suspension of growth in the length of the bone, after the injury to an epiphyseal carti- lage. Never forget to warn the parents of a hare-lip patient that one operation is often inadequate. Never forget to warn your patient that the loose cutaneous anal tags always swell temporarily after an operation for piles, or he may suppose you have overlooked them, and that the operation is incomplete. Never forget to warn your patient that a Mei- bomian cyst fills with blood after being scooped out, or he will think the operation has been per- formed in a slovenly manner. Always warn the patieilt's friends that fluid tak- en by the mouth may run out through a .trach- eotomy wound for the first few hours, and that this is not due to a wound of. the gullet. Always make your patient with angular curv- ature understand that no visible improvement in the deformity can be expected from the use of the WARNINGS AND CAUTIONS. 79 supports, but that they are ordered to relieve pain, and prevent further displacement. Always warn your elderly patients that a contu- sion of the hip sometimes causes shortening, es- pecially if the case be the subject of rheumatic arthritis. Remember that consent is necessary to make an operation legally permissible. The question from whom consent must be obtained is not clear in all cases. In operations upon a wife for instance, some courts have held that the husband's consent is necessary. A surgeon must keep within the strict scope of authority expressly given him, or he must be able to show that he had permission to do whatever might be found necessary during the procedure. 80 GOLDEN RULES OF SURGERY. ABDOMEN. Always avoid purgatives in treating a patient who has swallowed a foreign body. Give opium and constipating food — boiled eggs, cheese, pud- ding, potatoes, etc. ; a few days later you may purge. Remember that opium masks the symptoms of strangulated gut, appendicitis, and peritonitis, and may deceive both surgeon and patient in gauging the urgency of the case. It is a good rule to give a purge when tempted to give opium in obscure abdominal pain. The purge cleans and clears, the opium obscures and obstructs. Remember it is the atony of long continued ob- struction which causes the mortalit)- of colotomy, not the operation itself. Long continued disten- ABDOMEN. 81 tion is accompanied by paralysis of the coats and vice versa. ' Never procrastinate in strangulated hernia. Re- duce by taxis or operation at the-earhest possible moment. Remember that about one half of all strangula- ted hernias v^^hich have resisted taxis without re- laxation v^rill slip back under complete relaxation brought about by an anaesthetic. It is a good rule to v^^ash out the stomach and also the colon "before proceeding to reduce by taxis or to operate under anaesthesia, when there has been much vomiting or where the hernia is of large size. Remember that the abdomen has become the favorite field of the operators who don't know much about anatomy. It is so easy to remove cer tain little superfluous or troublesome organs. Be- ware of the pelvic surgeon "limited." Do not forget that "belly-ache" in a child may indicate the passage of uric acid gravel from one or other kidney. 82 GOLDEN RULES OF SURGERY. Do not omit to examine the spine of a child who has a grunting respiration or a frequent belly-ache continuing at intervals for a long period. These symptoms are both significant in Pott's dis- ease. Never give a positive diagnosis of an obscure abdominal tumor until you have examined the patient after purgation and under anaesthesia. The removal of abdominal tumors is the sur- gery which is most showy and satisfactory in its results. It is also most interesting, because no two tumors are exactly alike. Malignancy is found only in about ten per cent, of the cases. Remember that very large solid abdominal tu- mors in children are very frequently either renal or retroperitoneal sarcoma. Uterine myoma and ovarian cysts are the sur- geon's delight, but occasionally one of these tumors may tax the resources of the operator to the ut- most. I have done resection of intestine and trans- plantation of one ureter while removing such tu- mors. ABDOMEN. 83 Remember that an inflamed appendix is the most frequent cause of obscure suppurative peri- tonitis. Do not diagnose every pain in the position of the appendix as appendicitis. In women salpin- gitis is about as frequent as stricture in men. Remember there is such a disease as descend- ing renal calculus on the right side, and it simu- lates appendicitis. In kicks or blows upon the abdomen by a blunt object, for instance a horse's hoof, there may be no external sign of injury, but the intestines may be ruptured. Lose no time in opening and draining. Do not trust the temperature too much in real appendicitis. Watch the pulse to judge if suppu- ration is commencing. Remember, a rising- pulse rate of 110 after free action of the bov^^els and exclusion of typhoid, gen- erally indicates necessity for surgical intervention. 84 GOLDEN RULES OE SURGERY. Never probe* any punctured wound in the ab- dominal or thoracic wall. This rule does not ap- ply when the surgeon is prepared and ready to do an aseptic operation. Always relax the abdominal wall after sutur- ing a wound of the parietes. Never close any wound of the abdominal wall till all haemorrhage has ceased. Never under any circumstances apply pressure to a wound of the abdominal wall to arrest haem- orrhage. There is little or no danger of perforation of an intestinal ulcer by giving a purge. There is al- ways a negative pressure inside the small intestine. If this were not true, no method of suture would hold. Never mind increasing a superficial wound of the abdomen in order to remove a tumor or to secure k bleeding point. The best method of giving rest to the over- *"A probe in the hands of a dirty or rough surgeon is like a loaded pistol in the paw of a monkey." ABDOMEN. 85 worked or diseased intestines is to clean them out by castor oil or salines and not by opium. Never neglect to pass your finger fairly through the wound when replacing protruding viscera, in order to make sure that the reduction has been complete ; and be careful never to push the bowel into an interstice between the muscles or into sub- peritoneal tissue whilst reducing. Never ligature a large piece of omentum en masse. Do it piecemeal, for the constricted edge of the apron of omentum may become withdrawn from a single loop, and fatal haemorrhage result. Never forget that all abscesses of the abdomi- nal. wall should be opened freely and at once. Never hesitate or delay to open and drain an abscess in the loin, due to rupture or injury to the kidney. Never aspirate for ascites, or for any fluid col- lection in the peritoneal cavity, without first empty- ing the bladder. Never aspirate a large ascitic collection quickly. Do it slowly, so as to avoid shock. This rule holds 86 GOLDEN RULES OF SURGERY. good for thoracic and vesical as well as for intra- peritoneal collections. Never aspirate a suspected renal tumor through the peritoneum. Enter posteriorly below twelfth rib. The time patients are required to remain in bed or in the hospital after abdominal section, has been very much reduced. A few days only are now required after extensive operations, where formerly six weeks were insisted on. After appen- dicectomy or radical cure of hernia, patients may sit up after 4 or 5 days and may often leave the hos- pital after one week. This rule applies only to afebrile cases with primary union. IRRIGATION AND DRAINAGp;. Irrigation and Drainage in Abdominai, Surgery. Never irrigate over a wider area than has been contaminated. Never use pure water — it is irritating — always saline, 1 per cent. When the infection is limited to the pelvis, limit the irrigation strictl)'- to this part. Never forget the renal fossae in drying out the abdomen; much fluid is liable to collect there. "Drainage is rarely of value and often harm- ful," says Howard Keely, vol. II, p. 29. But I do not agree with this bald statement. Drainage is often of great value and is rarely harmful. I have saved many lives by drainage after appendix and pus-tube operations. This is not the place to har- monize the two contradictory sentences. Both are right, both are wrong, but in quite different cir- cumstances. If both methods seem applicable then 88 GOI.DEN RUIvES OF SURGERY. the operating surgeon must decide which method he will follow and let no man censure him for his choice — for he will know best which method is suited to his plans as he has learned to use them in previous experiences. While on the subject of drainage remember the great part which the lymphatics play in disposing of poisonous and waste matter. ABSCESS. 89 ABSCESS. Never try fluctuation across a limb, always along it, but remember that there may be fluctua- tion, even though you can not detect it. Let some other surgeon try his sense of feeling. Never forget that : — 1. — Abscesses near a large joint often com- municate with the joint. 2. — Abscesses near a large artery sometimes communicate with the artery. 3. — Abdominal wall abscesses sometimes originate in affections of the hollow or solid viscera. If the abscess is widely opened, drainage with gauze will suffice without irrigation. Dispense with irrigation whenever you can get along with- out it. 90 GOIvDEN RULES OF SURGERY. Never forget that early openings are imperative in abscesses situated: 1. — In the neighborhood of joints. 2. — In the abdominal wall. 3. — In the neck, under the deep fascia. 4." — In the palm of the hand. 5. — Beneath the periosteum. 6. — About the rectum, prostate and urethra. After incising the skin introduce the aseptic finger and be sure that any side-pocket is also drained. To wait for abscesses to "point" or to "burst" in these situations is culpable as well as cowardly. There is no danger of infecting an abscess by its own contents. The walls surrounding the abscess are prSbably immune to the germ poison they con- tain. Of course you can introduce foreign germ poisons if fingers and tools are not clean. Remember the frequency with which haema- tomata and traumatic aneurysms have been mista- ken for abscesses, and ha\e been incised with un- toward results. ABSCESS. 91 Do not open a collection of pus anywhere near a large artery without first using a stethoscope. It is best to incise an abscess thus situated by Hil- ton's method (i. e., scalpel, director, and dressing forceps). Never under any circumstances use for explora- tory puncture "that surgical abomination— a grooved needle" — for it causes contamination of all the tissues through which it is withdrawn, if it has entered an abscess. (Thornton.) Never plunge in opening abscesses ; never squeeze 'the sac after opening. Always use the moist antiseptic pack after opening an abscess. The moist antiseptic dressing has taken the place of the old poultice. It is better in every way. (See "Moist Dressing.") Do not forget that your incision should radi- ate : 1. — In abscesses pointing near the nipple. 2. — In abscesses near the anus. 3. — In scarifying chemosis of the conjunctiva. 92 GOLDEN RULES OF SURGERY. * And that your incisions should be longitudinal : 1. — In the hand. 2. — In the perineum. 3. — On the vertex. Do not forget that incisions for superficial ab- scesses in the neck and face should run parallel with the wrinkles and folds. Do not be afraid of hurting the lacteal tubes in mammary abscess. More harm is done to the gland by the burrowing of pent-up pus, than by a free incision. Never make a palmar incision for abscess ex- cept in the middle of the lower third and in the axial line of the fingers or at the sides of the palm. Do not forget, in opening a deep abscess in the lumbar region, outside the bulging area, to cut down opposite a transverse process for fear of wounding a lumbar artery. Never go deeper than for four inches into the liver when aspirating, by this means you avoid the inferior vena cava. Remember the sinus or fistula is the relic of a former abscess and that if it does not heal and ABSCESS. 93 close permanently under the influence of rest, ar- tistically and scientifically applied for a sufficient time, a radical cause must be sought and removed. Never neglect the hint which the guardian pap- illae give of the irritating focus deeper dow^n. Remember a dirty probe will cause fever ; even a clean probe energetically used may cause fever by baring the granulations lining the sinus. The mere curettement of a sinus, if it does not lead to the discovery and removal of its cause is useless. Never neglect to slit up the forks and the bur- rows of the sinus or fistula as well as the main channel. This applies not only to perirectal but to all fistulas wherever located. In order surely to find all forks and branches of a sinus the injection of a staining fluid will aid the surgeon so that none will be overlooked. Methylene blue or pyoktanin solution is good for this purpose ^nd may be injected with considerable force. (C. H. Mayo.) 94 GOLDEN RULES OF SURGERY. ANEURYSM. Never attempt to cure an aneurysm by the for- mation of a thrombus if the patient has any septic condition (such as an abscess, sore, suppurating otitis), for such may induce yellow softening of the clot. Extirpation of the sac is the best method of cure. The old Antyllus method of ligating above and below the sac and removing the latter is the best as well as the most radical method where the anatomical relations will permit its performance. It should be used to the exclusion of those meth- ods which merely ligate the artery and leave the sac. This operation is now often successfully done because it has lost its former dreadful mortality since we operate aseptically. ■ Aneurysm of the aorta is a noli ine tangere. Asepsis has left some lesions in the class of inop- erable cases. APPENDICITIS. 95 APPENDICITIS. When a surgeon sees a case of appendicitis within 12 hours of its inception and can operate before twenty-four hours have passed, he may re- joice, because he has an excellent chance to save an endangered Hfe. He will succeed ninety-nine times out of a hundred. If a surgeon is called after twenty-four hours have elapsed and can not operate under favorable conditions before another twelve hours or longer have elapsed, he must not always operate. The death rate is high when operations are done during the acute attack after the first thirty-six or forty- eight hours have elapsed. The time will come when physicians who allow the most favora.ble time to pass by and call for a surgeon too late, will receive censure. I am, as a 90 GOLDEN RULES OF SURGERY. matter of fact, of the opinion that the time for such censure has now arrived. (1906.) I am as a matter of principle in favor of the prompt operation in all cases when seen early- enough. In those cases where, because of failure to make a prompt diagnosis, or for some other reason, the first thirty-six hours have passed, the expectant- purgative treatment should at once be instituted if the operation is r'egarded as too dangerous. This expectant treatment will lead to a cure, or rather to an apparent cure in about 80 per cent, of the cases. Of the other 20 per cent, perhaps 5 . per cent, will require operations of drainage in or- der to save their lives and will be very ill for weeks and months, the remaining fifteen per cent. will die. The prompt radical operation done during the first twenty-four, or at the longest, thirty-six hours, has a mortality of one per cent ; the expectant treatment a mortality of fifteen per cent, and in APPENDICITIS. '.'7 many cases a long siege of fever and confinement in bed. An interval operation for the removal of the impaired and adherent appendix will be necessary in a large number of those who have escaped with their life under the expectant treatment. Exactly how many of this 85 per cent, will submit to the interval operation we never can know, but their number is constantly growing. I consider the interval operation a safe one and believe it should be done in 'nearly all cases. Its mortality is below one-half per cent. This means that less than one out of two hundred cases will die after the interval operation in the hands of an aseptic and skillful operator. At the meeting of the German Society for Sur- gery in 1905, the consensus of opinion of those who have had the largest experience* was in favor of the early operation as a routine practice, before 36 hours have elapsed. We American surgeons have entertained this opinion for some years past, but have met with opposition from the general practitioners. 98 GOU)EN RULES OE SURGERY. Let the general practitioner remember that the mortality of appendicitis operations done on the 3d, 4th or 5th day is from 15 to 20 per cent, and let him also know that the mortality in cases done before thirty-six hours have elapsed is only one per cent, in the hands of the same surgeons, and he will soon realize that the safety of his patients lies-in prompt diagnosis and operation. I once had the great luck to operate on seventy cases of acute appendicitis in succession without a death. I call it great luck in the light of subsequent experience, because I have never had so low a mortality again, although my experience and my technique have grown since then.. Some of these cases were late cases done on the 4th, 5th or at a much later time. The majority of course were early cases, but some had diffuse peritonitis. This was in 1894 and '95 when I operated on all acute cases as a matter of principle, no matter when called to see them. I desire here again to emphasize my view based on a large series of cases, that the expectant pur- gative method of treatment vvill get better re- sults in the hands of the general practitioner than APPI^NDICITIS. 99 the opium-starvation-treatment of long ago, which by some has been called the Ochsner treatment. In these unoperated cases of appendicitis we are dealing with cases that were formerly called cases of peritonitis or perityphlitis. In these cases we are combating septic absorption of putrid ma- terial located both inside and outside of the intes- tinal tract. I consider that the best method is to enhance elimination by purgation. In my opinion the physician will do well to give an enema of warm water and some small doses of calomel, as soon as he- recognizes appendicitis. The operator who may perform the operation a few hours later, will find his work much easier if the bowels have been cleaned out, than if they are expanded by gas and faeces. Even if an operation is not done the ex- pectant treatment will have the benefit of this evac- uation of the bowels, which is always accompanied by more or less of an elimination of waste material which has accumulated in the intestinal sewers. Remember that at the present time we have no way of kno\\'ing before the operation whether it is the bacillus coh\or the streptococcus or some other kind of infectious micro-organism which is con- 100 GOLDEN RULES OE SURGERY. cerned in any given case of appendicitis. This is one of the plainest reasons why we can never offer a prognosis in a case of appendicitis and should al- ways recommend prompt removal of the organ. The reason why appendicitis is so frequent, is because the appendix is a rudimentary organ. A rudimentary organ is one that has lost its useful- ness. It is one that is on the list of organs which is being abolished by the slow process of evolution. Organs of this kind are not well equipped with vitality or with resisting power. Their blood ves- sels, lymphatics and nerve supply are also grad- ually being evolved out of existence. Hence this organ is so frequently found undergoing processes of degeneration and of necrosis, which lead to fatal peritonitis in very many cases, unless prompt re- moval of the organ is effected. That the appendix vermiforfnis in man is a ru- dimentary organ is proven by the fact that it is proportionately much larger and wider and longer in a foetus of three months than at birth of the child or at any time later. Remember that while performing appendicec- APPENDICITIS. 101 tomy, there is danger of hernia following a large incision. But do not make the incision so small as to hamper you in doing a perfect and com- plete operation. An interval operation rarely re- quires a long incision and during the acute stage the incision will probably always be longer in late cases than in the yery early ones. Another reason for the prompt early operation. That the autoptical method of pathological study or research has great advantages over the autopsical or riekropsical method is easily under- stood. Aseptic surgery has given us material in plenty for macro- and microscopical examination taken from the living and curable patient intra ■mtam. The post-mortem, or autopsical, method of pathological research acquaints us only with the terminal or incurable stages of disease. Our modern knowledge of appendicitis has been much advanced by autoptical observation in vivo and would still be in darkness if we depended on the old post-mortem pathology. 102 GOU>EN RULES OF SURGERY. ARTERY-BLEEDING. Always tie both ends of a divided artery in a wound. The best ligature is catgut. Bartlett's method of preparing it seems to make the most useful threads. It i? strong and also elastic. Unless there is a valid reason against it always use catgut for suture or ligatures. Remember that not every little artery needs tying; a clamp left on for a few minutes often suf- fices and avoids a foreign substance in a wound. Use as thin a ligature as seems consistent with the required strength. Avoid thick sutures and ligatures. Twisting arteries is just as safe as tying — when well done it is the preferable method, but it is not so easy as tying and should not be used by inex- perienced surgeons. Learn how to do it. ARTERY BLEEDING. 103 Remember that arterial haemorrhage must be checked at once and permanently and that there can be no exception to this rule, because death in- evitably follows the loss of blood, if it persists. On the other hand it is important to know that the organism can stand the loss of large quantities of blood. I have seen strong men or women re- cover who had lost 6 or 8 pounds of blood. A man weighing 150 pounds has about 12 pounds of blood in circulation, and the loss of one half of it will not kill unless it spurts out of a large artery in a few minutes. In tjiis event, by proper treatment of the shock recovery often takes place. Proper treatment will be infusion of warm salt solution by subcutaneous, intraperitoneal or rectal injection. Direct intravenous transfusion of fluids of any kind is not to be commended. It seems safer to have the fluid enter the blood vessels after having passed through a cell membrane of some kind. The use of strychnine, digitalis or other poisons by hypodermic injections is not recommended, be- cause they do more harm than good and often kill weak patients. 104 GOLDEN RULES OE SURGERY. BONES AND JOINTS. Always hesitate to diagnose in an off-hand way "rheumatic" pain in young children, and those about the age of puberty. Remember acute peri- ostitis simulates rheumatism very closely. Remember that the diagnosis of "growing pains" in children is slipshod and usually incorrect; that it has been known to cover myalgia from fa- tigue, rheumatism, diseases of the joints and bones of the lower extremities, even fevers. Never delay in acute osteo-myelitis or in acute infectious periostitis to cut freely down to a bone as soon as the nature of the case is detected. Every hour of delay may need a month to repair. Do not forget the three golden rules in acute osteo-myelitis of the fulminating type: 1. — Prompt incision. 2. — Free incision. 3. — Free drainage. BONES. 105 Remember secondary abscesses may form in acute osteo-myelitis. Be therefore on the qui vive for such. Do not be disappointed if, on making incisions down to the bone, you evacuate but Httle pus in acute osteo-myelitis. It makes no difference, the relief afforded is often the same. Remember the golden rules for removing se- questra from long bones after necrosis. 1. — Do not wait for the periosteal sheath (new bony sheath) to acquire strength enough to preserve the continuity of the limb. 2. — Always remove the sequestrum as soon as possible, for it is : i.- — A permanent source of irritation. ii. — A danger to the adjacent parts. 3. — Do not leave any dead bone behind. 4. — Always splint carefully and bandage to maintain the parts in apposition and to prevent fracture. Never forget that there is no periosteal sheath in the necrosis of the femur in the popliteal space. 106 GOL,DEN RULES OF SURGERY. and that the eMoIiated bone Hes close under the popliteal artery. In removing such a sequestrum avoid four things : 1. — Joint. 2. — Artery. 3. — External popliteal nerve. 4. — ^Rough manipulation. Do not use the knife. Separate with the han- dle of the knife or other blunt instrument. At the present time the rule is : Amputate where the limb-maker can best supply the loss. The old points of selection are not always the best. JOINTS. 107 Joints. Remember that chronic joint disease in most cases originates in the bone and is tuberculous. Even when a trauma is given as the cause, it is usually not the primary cause, the latter is likely to be a tuberculous focus in an epiphysis near the joint. Never bandage an elbow in the extended posi- tion excepting after fracture and wire suture of the olecranon. Do not be hasty with the knife in dealing with fluctuating swellings near a joint. [There are changes in the synovial membrane which produce thickening and suppuration, which can with diffi- culty be distinguished from an external circum- scribed abscess.]. Never forget that the synovial tissue of thecae 108 GOLDEN RULES OF SURGERY. embracing tendons, may pour out a considerable amount of fluid or even pus. [The accumulation of fluid in a joint or in the layers of the synovial mem- brane or in tendons and bursae rarely affects the integument. Therefore, unless there is external redness never use the scalpel hastily.] Never probe any joint in clean cut wounds open- ing the joint, unless a foreign body is known to be lodged therein. Always persevere with rest and counter-irrita- tion in disease of the shoulder-joint as long as there is pain produced by motion, but no longer. [Pro- longed confinement is apt to produce adhesion of the lower part of the capsule, and permanently to deprive the patient of the power to raise the arm]. Always trace all sinuses near the shoulder to their source, because the tendons often direct the pus to some point distant from the joint. Always consider the chance of subacromial bur- sal disease before you diagnose disease of the shoulder-joint. JOINTS. 109 Do not hesitate to aspirate a joint for diagno- sis, but remember it is criminal to do so witliout strict aseptic precautions. Never neglect to put all tuberculous joints at rest. [Rest should be maintained for three months after all signs of disease have vanished, and active exercise must even then be very gradually re- newed]. Never neglect early movement in chronic ar- thritis; never allow early movement in tuberculous arthritis. Never insist on maintaining fixation of joints for over long during the treatment of accident or disease of the limb itself. Never forget whilst breaking down adhesions in a joint: 1. — The atrophy of bone which rest induces. 2. — The buried bacillus. 3. — The fragility of a child's bone. Hence in breaking down adhesions do not omit to hold the bones as near the joint as possible. 110 GOI,DEN RULES OF SURGERY. Do not do too much at once. Rupture adhesions by short movements in the way of flexion. Divide contracted tendons some days before breaking down adhesions, and put on the ice-bag in every case afterwards. Beware of employing brisetnent force in tu- berculous joints. [Numerous cases are recorded where this procedure was followed within a few days by general miliary tuberculosis and a speedy dieathj. Never attempt to overcome muscular contrac- tion by forcible extension in remedying malposi- tion of joints — tenotomize. Do not let a child wearing a Thomas' splint have a hard bed, for the splint on a hard mattress is thrown out into relief, and causes painful pres- sure. Never forget that the rapid loss of tissue ob- served about a joint in serious disease of the ar- ticulation is never seen in hysterical joint. Remember that in making a resection of dis- eased, tuberculous joint ends of bone the soft parts JOINTS. Ill surrounding the excised area, though perforated by numerous old fistulae or sinuses, need not be removed. They will all heal up if their cause has been removed by the operation. Beware of the insidious onset of tuberculous arthritis. Never regard the case of a limping child light- ly. Examine the hip. Never omit to examine the hip when pain is complained of in an apparently healthy knee. Never forget that proof of knee disease is no proof of the absence of hip disease of the same side. If it is possible to give a diseased joint perfect rest, by means of bandages, splints or casts, and to supplement this treatment by outdoor life in a suit- able climate, the results of the treatment of dis- eased joints are most satisfactory. If ever you must exarticulate at the hip joint, ligate the common iliac artery transperitoneally first. This little operation will take a few minutes and will render the amputation much easier and BREAST. 113 BREAST. Never forget that a "tumor" in a young wom- an's breast is frequently a chronic abscess, or a cyst. Never procrastinate wth a tumor of the breast in a female over forty. Never excise a mammary tumor of doubtful nature without first cutting it across to examine its character. Never remove a true carcinoma of the breast without clearing out the axillary glands. Do not hesitate to remove the major and minor pectoral muscles, if you find hardened lymph glands under them. Never be too anxious to make your flaps meet and look well, in removing a cancer of the breast. Your vanity might tempt you to leave a flap in which cancer may lie concealed. 114 GOLDEN RULES OE SURGERY. Although the temptation to do so is great, don't try to cover the wound with skin likely to contain cancer nodules. If you make a plastic operation by transposing a skin flap let the skin flap be taken from a distal location, distal referring to the course of the lymphatics. When extirpating a malignant tumor in the hope of achieving radical cure always remove the proximal lymphatics for a space of from three to six inches or more. This applies to all localities not only to the axilla. Remember that not only must a flap have arte- rial blood supply, but that the outlet or exit by the veins must be freely maintained. It is as important for the life of the flap as the arterial supply. BURNS. 115 BURNS. Never give morphine hypodermically in burns of children; you cannot recall it. Give ,it by the mouth if indicated at all. Relieve pain by moist dressings of the proper M^armth and alkalinity. Gauze saturated with sterile carron oil is a good dressing. Never omit an anaesthetic in the first dressing of extensive burns. Excellent results can be ob- tained by the simple aseptic or antiseptic moist dressing. (See moist dressing.) Beware of strong application of carbolic oil in burns, and, if it be used at all, watch the urine for absorption signs (a greenish brown coloration). Do not dress too often, but never let the dress- ings foul. Never uncover the entire wound at once ; do it piecemeal. 116 GOLDEN RULES OF SURGERY. Always have the tracheotomy instruments at hand in burns and scalds of the mouth, because of oedema of the glottis. Remember the deformities which ensue on con- traction of cicatrices of burns, and attempt to pre- vent them by grafting, etc. CHEST. ■ 117 CHEST. Do not be very solicitous in obtaining crepitus of a fractured rib. Treat it as such. Do not handle portions of two different ribs in manipulating either side of the fractured rib to ob- tain evidence of undue mobility. Never forget that all penetrating v\rounds of the chest, involving fracture of ribs or not, should be closed at once and a plaster of Paris jacket put on at once. This is the most successful method of treating penetrating gunshot v^ounds of the chest. Do not forget that it is good practice in severe cases of fractured ribs, and in those in which the lung is wounded, to support the chest by com- pletely encircling it with plaster of Paris bandages. These are applied over the wound dressing. [Ban- daging is said to be contraindicated if there is much 118 GOLDEN RULES OF SURGERY.. comminution or tearing of the parietes of the chest ; or: 1. — If dyspnoea increases on its application. 2. — If pain is caused by it; but I have found that breathing becomes easier and regular after a strong supporting bandage encir- cles the chest. Diaphragmatic breathing must take the place of costal breathing and nearly always suffices. Do not strap or bandage, if there is much sur- gical emphysema. Strapping is worse than useless if it only partly encircles the chest; to do good it must go clear around. Always regard rib injuries in old people with anxiety. [There may be, and usually is, pre-exist- ing emphysema and bronchitis which will hamper the breathing greatly.] Be cautious in fractures of the ribs about ex- hibiting opium if the sputum is very viscid or very abundant. In the former case its tenaciousness is increased by the drug; and in the latter the nerv- ous reflex is dulled, and the stimulus for the con- CHEST. 119 stant removal by coughing is lessened. Whiskey- is preferable to opium if either is called for. Never tap a chest in paracentesis without mak- ing certain by auscultation and percussion that you are on the right spot. Always use an exhaustion syringe in tapping the chest. Never forget in this, as in all other as- pirations, to run some carbolic or hydrarg. perch- lor. solution through your cannula and exhaustion bottle before operating. Do not forget your land-marks (upper border of lower ribs). Do not forget also that too forcible a suction applied to the vascular false membranes, which often occupy the pleural cavity, may give rise to haemorrhage into the pleura. Always stop the aspiration if pain is complained of. Do not neglect, in treating empyema, to secure your drain tube from slipping into the thorax. Let it be sufficiently, and only sufficiently long to enter the cavity. Longer is needless. 120 GOLDEN RULES OE SURGERY. Never forget that irrigation in empyema is rarely necessary, and is often fraught with serious danger. Leave the wound wide open for drainage. If perfect drainage is secured irrigation will not be needed. Moist dressing. Syncope, convulsions, and even death, due to reflex action, have been recorded. If it is necessary to irrigate, as it is exception- ally, never use a large amount of fluid; never throw it into the cavity roughly; never when the patient is sitting up; and never continue if pain is complained of. EAR. 121 EAR.* Never forget that rupture of the membrana tympani, or even fatal consequences, may ensue from roughness in removing foreign bodies. Remember that no foreign body in the ear, ex- cept living insects or vegetable substances, can do harm. Syringe gently, unless the foreign body is likely to swell. Never forget that vegetable substances svi^ell in the auditory canal on the application of vi^ater. Never forget the possible dangers of a dis- charge from the middle ear. Remember that there may be no discharge from the ear in lateral sinus pyaemia. Do not be thrown off your guard and decide against lateral sinus pyaemia because the dis- • Taken from Hurry Fenwick. 122 GOU>EN RULES OP SURGERY. charge from the ear is inodorous and small in quantity. Always examine most carefully the nose and naso-pharynx in all cases of deafness for which no adequate cause has been found in the ear itself. Remember there is hardly any ear disease which may not be improved by removing any ab- normal conditions in the nose or naso-pharynx of a patient. A nasal polypus may cause deafness as well as a mass of adenoid growth. Remember, a running ear may be often cured by clearing the post-nasal space. ERYSIPELAS. 123 ERYSIPELAS. Never deplete or depress in erysipelas. Sup- port and stimulate. Do not dress operation or fresh wounds, or at- tend midwifery, if you are dressing a case of ery- sipelas or any contagious or infectious disease. It is in erysipelas that the moist pack, partic- ularly the moist bichloride of mercury pack, has its most striking and gratifying results. In mixed infections and lymphangitis of all kinds you will be able -to achieve therapeutic triumphs by this method. (See Moist Dressing.) 124 GOLDEN RULES OF SURGERY. FEVER. Remember the real danger in fever is not the pyrexia, but the poison causing it. Fever is, in a measure, a beneficial process operating to protect the economy. The elimination of the poison by the skin, kidneys, liver, and intestines is the thing to be encouraged. Always view with anxiety any case of sepsis which has a low temperature and a rapid pulse. The prognosis is more favorable when the animal economy- responds with a positive but controllable pyrexial process, than when there is very little feb- rile reaction. I have seen no harm from the use of properly prepared antitoxic serums, but have not seen the excellent results claimed for them. They are still sub judice. The whole theory reminds me of the old humoral pathology and is not scientifically es- tablished. Festina lente! FEVER. 125 To drive down the temperature by means of antipyretic coal-tar products is sometimes harmful. Symptom treatment before the diagnosis is always fighting an unknown enemy in the dark, conse- quently always uncertain and unsafe. 126 GOLDEN RUIvES OE SURGERY. FRACTURES AND DISLOCATIONS. The principles underlying the treatment of frac- tures may be stated as follows: 1st, correction of deformity by reposition or reduction of the frag- ments ; 2nd, retention or fixation of the broken bone after the displacements have been put into apposition, by suitable retention dressing or appa- ratus until bony union has taken place. In compound fractures the wounds will be treated antiseptically and unless the compound fracture can be made into simple fracture by su- ture of the wounds, means of drainage and anti- septic wound treatment will have to be provided for in conjunction with the cast or apparatus of fixation. Should attempt at making a simple out of a compound fracture fail, as will be shown by the thermometer on the second or third day, all dress- If'RACTURES AND DISLOCATIONS. 127 ings must be removed and the free drainage pro- vided for at any cost of trouble and time, amputa- tion may be indicated. The use of the plaster of Paris dressing of frac- tures must be acquired by all surgeons and is not at all easy or simple. It can be learned only by experience. The thing to be learned is how to achieve fixation and rest without undue pressure. Flannel banda-ges under the plaster are preferable to cotton batting. Next in importance to learning the use of plas- ter of Paris is to learn that anaesthesia will facili- tate the perfect reduction or setting of fractures and dislocations and that complete relaxation of the muscles by chloroform or ether insures an exact diagnosis and also a more accurate reposition and restoration of the broken or displaced structures. in: Remember that crepitus may not be obtained 1. — Riding of fragments. 2. — Impaction of fragments. S.^Entire separation of fragments. 4. — When muscle or blood clot is interposed between fragments. 128 GOLDEN RULES OF SURGERY. Remember that there is a pseudo-crepitus, very Hke true crepitus, in teno-synovitis, joint effusion, osteo-arthritis, and caries of a joint surface. Do not forget that in epiphyseal fracture your prognosis must be guarded, because such injuries to the young are sometimes followed by suspended growth or by premature ossification of the bone. Deformity is thus produced. Remember, in separation of epiphysis in the up- per extremity of the humerus and the lower ex- tremity of the femur, the line of fracture is so broad that there will be no shortening, but the fragments will project. Always examine at once the pulse at the wrist and ankle in fractures of the humerus and femur, to ascertain if the artery has been torn. Never allow a splint to press on the skin, so as to cause ulceration or oedema, or worse, gangrene. Do not in fracture of the acromion put a pad in the axilla, or bandage the elbow too tightly to the chest, because the head (the natural splint in such fractures), is thrown outwards and the frag- ments are separated. Fractures and dislocations. 129 Never forget to examine the shoulder joint in every case of fracture of humerus situated high up, in order to ascertain whether the head be dis- located or not. Never omit in fracture involving the elbow joint to commence passive motion on the seventh day — certainly not later than the fourteenth day. Do not splint the palm of the hand in Colles' fracture ; leave the fingers free, and work them after the third day, for the tendons as they cross the back of the radius — the seat of fracture — are apt to become adherent to their grooves. Never let your diagnosis be "only a contused hip" in old people, without a very careful and gen- tle examination to exclude impacted fracture. Do not forget that though absorption and change in the head and neck of the old femur is not so common as is taught, yet it does take place as the result of chronic osteo-arthritis, and may simulate fracture in the shortening, eversion, and osteophytic crepitus, which are so often pres- ent. 130 GOLDEN RULES OE SURGERY. Never use violence in order to elicit crepitus in cases of hip injury; much damage may be done in separating an impaction by rough examination. Do not keep your old patients in bed, in order to get union in hip fracture. They are almost sure to suffer from sloughing produced by the splints or from bed sores, and will very likely die. Never forget to bandage the entire limb in frac- tured femur. The best treatment is the plaster of Paris cast, bandage encasing the foot, leg, thigh and pelvis by spica, reinforced throughout with strips of tin, the whole applied standing, supported on the sound leg. See remarks about plaster of Paris. Remember the danger of traction by an exten- sion weight if a fracture be transverse above the condyle of the femur [the popliteal artery is ' brought into contact with the sharp edge of the lower fragment]. Always shampoo the quadriceps in a fractured patella, provided the state of the soft parts per- mits it. FRACTURES AND DISLOCATIONS. 131 Never place recent fractures in plaster of Paris splints (or other splints which withdraw the seat of fracture from the surgeon's observation), if there be much bruising, or until such has subsided. Always use fixation in recent fractures but ex- plain the danger of subsequent swelling to the patient and obtain his consent when the fracture is seen early enough. The two apparent contradictions just noted be- ing understood, the plaster of Paris cast is the best treatment for recent fracture. If it can be applied by one thoroughly familiar with its use and technique soon after the accident has occurred there will be but little swelling and no pain. Should there be pain after the plaster has set then probably the ap- proximation is faulty and must be changed at once. Should pain occur a few hours later and persist, then swelling has occurred and the cast must be removed and a new one put on as soon as possible. The neglect of this rule may, and nearly always does, bring on ischaemic paralysis with its ruinous sequences.* *See paper on Ischamic Atrophy, etc., after tight bandaging, in Boston Med. and Surg. Journal, June, 1900. by the author. 132 GOLDEN RULES OF SURGERY. Always suspect a bone that is fractured on silght violence. It is sugg'estive of disease^ e. g., central sarcoma. I have seen a man break his femur pulling on a boot under these circumstances. DISI.OCATIONS. 133 DiSIvOCATlONS. Never attempt to reduce a dislocation of the humerus in an old person without first examining the state of the brachial arteries to inspire you with caution and gentleness. You can produce trau- matic aneurysm if the arteries are atheromatous and brittle. [A case by Lord Listi;r, Lancet, Jan. 4, 1890]. Never put a booted foot in the axilla to reduce dislocation. Always reduce by some other method than the foot in the axilla if ribs are broken on the same side. Always clear up two points in treating injuries of the upper end of humerus. — Is there dislocation of the head? or. Is there fracture of the neck of the scapula ? 134 GOLDEN RULES OE SURGERY. Never give a positive opinion of an elbow joint until you have carefully examined the relations of the olecranon, internal and external condyles, and head of radius. Never be ashamed to say you "do not know" until the swelling has subsided, and you are able to be certain of the character of the injury. Always anaesthetize the patient if the disloca- tion is an old one and if there have been fruitless efforts at reduction made by others previously. The anaesthesia must be complete, and must pro- duce perfect relaxation of the muscles. Remember, however, that in dislocation at the elbow, the joint becomes rapidly irreducible, and that a faulty diagnosis may cause loss of motion in the joint. Always have obscure injuries to joints radio- graphed at once, if ways and means permit. Es- pecially do this in shoulder and elbow joint cases. Do not forget in dislocation of the carpal bones that the great point is to see that the motions of the fingers are restored early. DISLOCATIONS. 13.") After a luxation has been reduced the swelHng rapidly subsides, and the joint may be used after a short time of rest. Should the swelling and pain persist then either the reduction was imperfect or the bone has again slipped out of place. Should this accident happen the patient must again be anaesthetized and a plaster of Paris band- age applied before the patient awakens. 136 GOLDEN RULES OF SURGERY. GALLSTONE DISEASE. As long as stones are in the gallbladder the di- agnosis is not easy, because it rests largely upon subjective testimony of the patient and the trouble is often referred to the stomach. The operation of these cases is easy and the prognosis favorable, whether natural cholecysto- tomy or ideal cholecystotomy is done. Cholecystectomy should not be done as a rule unless the gallbladder is diseased. Obstruction of the common duct by a stone is easily diagnosed by means of the jaundice and other characteristic symptoms. In these cases the operation is difficult and dangerous. W. J. Mayo has done much to clear up this condition and I must refer to his writings for operative details. Drainage of the duct after removal of the stone seems the safest method of treatment. GAI,I,STONE DISEASE. 137 In this condition again early operation before serious complications arise is the proper thing. When the diagnosis is uncertain an explorative incision will be indicated in some cases. When the belly is open it is as well to look after the gallbladder as other organs. Gallstones are not so harmless as was formerly thought. 138 GOLDEN RULES OF SURGERY. GANGRENE. Do not mistake the line of discoloration in gan- grene for the line of demarcation. The former spreads, the latter rarely moves. In senile gangrene do not neglect the only drug of use— Opium ; give it while you are awaiting the time to do an amputation high up. Do not hurry separation of sloughs in frost-bite gangrene. Always treat moist gangrene with the antiseptic moist dressing. Give rest by suitable splint and change the dressing once a day. GENITO-URINARY. 139 GENITO-URINARY.* I. Bi,adde;r and Urethra. Remember that the "facies" of tubercle may not be noticeable in urinary tuberculosis, and that the "cachexia" of malignant disease only appears in the last stage of cancer of the bladder. Remember that the introduction of an instru- ment is more or less of an evil, never to be resorted to,' unless a greater evil be present, vi^hich its em- ployment may probably remedy. (Sir H. Thomp- son.) Beware of diagnosing hysterical retention in the female. Many v^^omen have suffered a life-long penance for a two days' unrelieved retention after parturition, or shock. False modesty, suspicion of hysteria, and negligence, have a heavy roll-call *Bladder and Urethra, Genital-Penis, Gonorrhoea, Kidney and Syphilis are taken unchanged from Mr. Hurry Fenwick's Rules of Practice. 140 GOLDEN RULES OF SURGERY. of ruined bladders. Better feed twenty drones than starve one bee. Better pander once or twice to twenty supposed cases of hysterical retention, than destroy the bladder of one healthy-minded woman. Never neglect to pass your hand over your pa- tient's belly in typhoid or any severe fever, or an injury to, or fracture of the spine, or in compres- sion, coma, or delirium, etc., in order to ascertain if the bladder be distended; for in these cases the bladder may be atonic and injuriously distended without distress. Never be content with simply washing your rubber catheter before using it in cases of fractured spine. Let it always lie in carbolic water 5 per cent. Never use force in passing catheters or bou- gies ; certainly never in cocainised urethrae nor in cases of fractured spine, because of the insensitive- ness of the urethra. [Every dresser or junior assist- ant ought to be induced to pass a full-sized bougie upon himself once or twice. He would then appre- GENITO-URINARY. 141 ciate the need for the utmost gentleness in urethral instrumentation.] Never pass an instrument if your patient is suf- fering from an acute inflammation of the testicle — unless you are relieving retention, or unless the orchitis occurs in a patient habitually using a cath- eter. Be especially gentle in passing instruments on a monorchid, for orchitis in his case is tantamount to sterility. There is, however, a greater danger : when one testis is congenitally absent, the corre- sponding kidney may be also absent. Never pass any instrument (bougie, catheter, sound, or cystoscope), until you have examined the prostate; for you may fiiid evidence there jus- tifying you in avoiding instruments. Db not permit yourself to talk glibly of "im- passable" stricture. Such cases are very rare. Pa- tience and a little sweet oil will often carry an in- strument through. Never under any circumstances dilate a stric- ture with a catheter — use an aseptic smooth-sur- face bougie. 142 GOLDEN RULES OF SURGERY. Never aspirate a bladder suprapubically with- out feeling it through the abdominal wall. Do not trust to percussion. Remember that success in the dilatation of stricture is now-a-days not s6 much a question of personal skill as of well-made, flexible instruments. Never pass a jointed or scre\\ed instrument, ^ such as an urethrotome-guide, into the bladder without testing the joint or screw. Never forget that some stones lie "latent," and do not evoke characteristic symptoms. [This is especially the case in prostatic atony]. Do not forget that a "large" calculus is often a sign of incapacity, or of carelessness on the part of the medical attendant. Never sound for stone during a "fit of the stone" (an attack of cystitis), or if there be any suspicion of cancer of the bladder, without great circumspection, for severe haemorrhage and ag- gravation of symptoms generallv follow in such cases. Never sound a patient suffering from "symp- ge;nito-urinary. 143 tomless" haematuria (intermittent attacks of bloody urine, without pain or bladder irritability, the urine being normal between the haemor- rhages.) Never be in a hurry to sound a young or mid- adult patient with vesical irritability well marked at night. Night irritability is the clinical indica- tion of tuberculosis of the bladder. Always boil your sound, and have your patient in bed when you sound. Let his bladder be full; elevate his pelvis on a hard pillow. Never omit to sound behind the prostate. Do not get your pa- tient up for twelve hours after sounding. Never forget that dribbling of urine in adult life usually denotes the overflow of a distended bladder. Never introduce a patient to catheter life with- out first giving him a course of urotropin (gr. vi: ter.) for three days at least. Give, always, ex- plicit directions concerning the cleansing of the catheter. Never under-rate the danger of an over-dis- tended "flabby" bladder in a male over fifty. 144 GOI.DEN RULES OF SURGERY. Beware of catheterizing an old man who has incontinence of urine, morning sickness, and pro- nounced thirst, whose bladder is distended well above the pubes, whose urine is clear, very pale, of low specific gravity, and abundant in amount. Explain the gravity to the friends. Never empty any bladder, and certainly never a lai'gely distended bladder, quickly or in the erect posture, unless the patient is accustomed to the use of the catheter. Remember it is a rule with no exceptions that a patient with hypertrophied prostate is never safe unless he can pass a catheter for himself, any more than is a patient with hernia who does not wear a truss. (Keyes.) Do not forget that irritability of the bladder is sometimes due to renal, ureteral or rectal irrita- tion. Never inject m.ore than 4 oz. at a time into the bladder, and that only with care. Never remove a catheter a demenre roughly or rapidly. [The abrasion of the canal by the eroded instrument has caused suppression and death]. GfiNITO-URlNARY. 145 Never put on a cantharides blister in nephritis, because of absorption (use Liq. ammon. fort.) Do not forget that a stricture whose caHbre has been found by a genito-urinary speciaHst to be No. 4 (French) often easily permits a 28 (French) to pass. — (Ohmann-Dumesnil) 146 GOLDEN RULES Of SURGERY. II. Genital-Penis. Never sanction a lengthy or an adherent pre- puce — circumcise. Never discard any damaged skin in stitching up scrotal wounds — the worst flap will heal. [Warm a wound of the scrotum before uniting it with su- tures; it is thus easily relaxed]. Always slit the urethra downwards in amputa- tion of the penis, and stitch the angles outward. This obviates stenosis as far as is possible. Always keep a catheter in position continu- ously in injuries to the penis if the urethra be di- vided. Do not tap a hydrocele without examining the position of the testicle with the light. Do not strap a testicle without shaving the scro- tum. GENITO-URINARY. 147 Do Jiot jump to the conclusion that every small knot in the epididymis is "tuberculous." Search the deep urethra. Do not give a decided prognosis of a solid slow- growing tumor of the testicle in which hydrocele co-exists before you have tapped the hydrocele and examined the gland carefully. It may be non-ma- lignant. If any doubt exists after this, advise a free incision, with permission to excise if neces- sary. 148 GOLDEN RULES OF SURGERY. III. Gonorrhoea, Never neglect to warn your patient about his eyes in treating a "first" attack of gonorrhoea. Always warn your patient of the possibility of an eruption when giving copaiba for a "first" at- tack of gonorrhoea. Never neglect in treating gonorrhoea! rheu- matism, to cure the discharge as speedily as possi- ble. Never omit to examine the penis for gonor- rhoea or gleet in searching for the cause of a spon- taneous knee synovitis in a young man. Do not hastily accept the statement of the pa- tient that a rash was syphilitic. In inquiring -into a history, find out whether copaiba was exhibited. ■ Never use an injection, unless it be cocaine, if there is much pain, scalding or inflammation. GENITO-URINARY. 149 Never forget, many gleets are due to slight con- tractions of the canal, and may be cured by a steel bougie. Remember that rest in bed, total abstinence, and light diet, together with purgatives and plenty of alkaline water, are the best and most rapidly successful measures in the treatment of a fresh case of clap, together with local cleanliness. Never forget that gleet in a patient who has had syphilis recently, conveys syphilis. 150 GOLDEN RULES 6E SURGERY. IV. Kidney. Do not forget that albuminuria does not neces- sarily denote Bright's disease. Remember that cases treated for "albuminuria'' years ago, have been lately proved to have had an oxalate stone in the kidney. Do not attribute much importance to a painless movable kidney if there are no symptoms of kink- ing of the ureter. (Frequency of micturition, un- satisfied micturition.) Remember that all kidne)- pain is not due to calculus : calculus is rare, whilst the pain of slight inflammatory lesions, either primary or ascending, is much commoner. Always remember that a small percentage of renal colic is due to tubercle of the kidney, or ure- teral folds or kinks. GENITO-URINARY, lol V. Syphilis. Do not adhere to the popular division of "hard" and "soft" sores. Do not believe or rely upon sharply defined rules for the diagnosis of chancre, even with sores which are obviously soft and non-infecting, until the incubation period (3-5 weeks) is well passed. [A so-called "soft" sore may become hard four weeks after coition, from having been inoculated by a. mixed secretion]. Remember acquired phimosis is so common an accompaniment of the three venereal diseases, — acute gonorrhoea, non-infecting sore, syphilitic sore, — that you ought never to express a decided opinion until you have obtained a look at the trouble. Do not hesitate to slit up the prepuce in order to examine and treat a sloughing sore. If you do not do this, the sloughing most probably will. lo2 GOLDEN RULES OF SURGERY. Remember the one simple rule for successful treatment of syphilis is, to keep inunction and fu- migation method for exceptional cases, and to give small doses of mercury' more or less frequently, but never large doses.* (Hutchinson.) Remember the earlier mercury is exhibited, the greater the probability that the symptoms v^rill be delayed or wholly prevented. Never be in a hurry to excise a syphilitic testis, however bad, even when there is abscess and fun- gus testis ; it will generally heal with patient treat- ment. Remember in tertiary syphilis whenever a case resists the iodide, and whenever it is important to obtain a rapid result, that mercury should be added to the iodide, or that mercury should be given alone. Remember syphilis may imitate all known forms of skin disease, but it can produce no origi- nals. (Hutchinson.) *Bemember it is better to get aloug with little or even with no mercury, because in spite of the strong evidence of experience, it is not proven that mercury is a specific— A. B. C. GENITO-URINARY. 153 Never forget that lichen ruber and lichen pla- nus are often dusky and copper tinted, and present all. the features which to those of limited experi- ence suggest a confident diagnosis of syphilis (Hutchinson). Remember that in rare instances syphilis imi- tates variola closely; there is, however: 1. — ^Persistence. 2. — Absence of odour. 3. — History to guide you. Do not sanction marriage in syphilis until three years after the date of infection, and then only if the patient is free from gleet, and has been thor- oughly and successfully treated with mercury. Never assume, as was formerly done, that mer- cury should be avoided when syphilitic sores ul- cerate; on the contrary, when used with iron, qui- nine, and opium, it will almost always prove the means of cure. Do not forget that the safety of the eye in syph- ilitic iritis depends mainly upon the promptitude and efficiency with which atropine is employed. 154 GOLDEN RULES OE SURGERY. Never neglect local measures in the lesions of intermediate and tertiary stages of syphilis. Remember that a node of secondary syphilis usually disappears or is prone to ossify, but a ter- tiary node, like other gummata, is more liable to suppuration and caries. Do not open a syphilitic bubo unless acutely suppurating, or a node of bone; they are usually absorbed. GENITO-URINARY. 155 Therapeutic Hints in Syphilis. Always prohibit smoking, and any diet which may lead to diarrhoea, while mercury is being given for syphilis. Never forget that some patients have an idio- syncrasy \vhich renders even small doses of the io- dides poisonous. Never forget that with a patient confined to bed and on low diet, ptyalism can be produced with half the dose of mercury. [N. B. — Rapid loss of weight means that mercury is disagreeing with the patient]. Remember that mercury is not well borne by the tuberculous, the cachectic, or by those having chronic renal disease. Never neglect to warn your patient about his gums and his tendency to catch cold, when taking mercury. 156 GOLDEN RULES OF SURGERY. In middle aged and elderly men, continued fe- ver with or without night sweats, may be syphilis in its late stages and nothing seems to cure except KI or the mixed treatment. Try KI alone at first. GOITRE. 157 GOITRE. Goitre becomes the object of surgical treatment either by symptoms of pressure it causes on adja- ^ cent organs, or by altered function of the gland which is usually called Basedow's disease. In both cofiditions partial extirpations of the growth give brilliant results. Follow Kocher's technique and the mortality will be very low. 158 GoijJEN RUL^s o:^ SurCeIry. HAND AND FOOT. Do not forget that it is wiser in cases of sup- posed needle in hand or foot, when the patient is not suffering much inconvenience, not to cut down unless the end of the needle is felt. It is wiser also not to attempt to remove the needle by its thread ; the chances are the thread will be pulled through the eye, or if it holds, the part above the eye will act like a barb. Use the thread as a guide to cut to the needle. Always radiograph, if possible, foreign bodies in extremities, and if you x-ray the hand, mark on the plate which hand it is. Never estimate the amount of flat-foot when your patient is sitting, because in this position the weight is taken ofif the arch, and your estimate will be false. Do not forget that the foot has been amputated HAND AND FOOT. 159 for supposed tuberculous disease of the tarsus, and on subsequent examination the affection has been proved to be limited to one of the tarsal bones, proving that the patient might have been cured by a less extensive mutilation. Do not despise or neglect corns, bunions, or ul- cers of the leg in the aged or diabetic. They often start gangrene. Never leave a sprain too long at rest. Pro- longed inaction is by far the most frequent cause of delayed recovery after injuries of the joints. Do not neglect to examine for ataxia before treating an ulcer of the sole. But do not diag- nose every ulcerating corn to be tabetic. Remember that sole, heel, and calf pains may mean ataxia, but they often demonstrate a pelvic (especially vesico-urethral) or renal focus of irrita- tion. Never forget that success in the treatment of club-foot does not merely depend upon a thorough tenotomy. It is gained only by months of careful manipulation, massage, and splinting after a thor- ough tenotomy has been performed. 160 GOI45EN RULES OF SURGERY. Infections and abscesses of the fingers and hand are among the most frequent minor surgical lesions you will be called upon to treat, and their treatment is so important that I will give a long paragraph to it under the heading of the Moist Dressing. These minor infections such as are known by the names of "felon," "panaritium," "carbuncle," "whitlow," "cellulitis," "lymphangitis," etc., often lead to major surgical operations and death if neg- lected or treated by men who do not properly ap- ply the principles on which their treatment rests. These infections must be treated by the com- bined application of antiseptics and rest." The antiseptic remedies cannot do their work unless access to the infected parts is given by in- cisions and drainage, after which the moist anti- septic poultice and rest by means of long splints will lead to the prompt relief of pain and a rapid cure. HEAD. 161 HEAD. Shave every injured head completely, put on a moist pack until ready to operate on it. Do not forget that an injury to the head is never so slight as to be despised, and never so se- vere as to be despaired of. Never forget that a blow on one side of, the skull often produces its main effects on the oppo- site side. Never close a scalp wound until all dirt is re- moved. Fill the external ears with cotton, clean out the, nose, the oral cavity, and purge every head injury case. Never hesitate to suture contused and lacer- ated wounds of the scalp, but in doing so do not forget the drainage. 162 GOLDEN RULES OE SURGERY. Never put stitches deeply into the scalp ; there is no reason to wound the tendon. If a patient is brought in unconscious, he either is drunk, or has a fracture of the skull, apoplexy or uraemia. You must make the diagnosis. Beware of cellulitis of the scalp when the deep- est layer of the scalp has been opened. In such cases do not be afraid of incisions, only let them run from before backwards, be 2 inches in length, and down to the bone. Avoid depletion or depri- vation of nourishment, because cellulitis occurs in the broken down. Never neglect to examine the sub-occipital glands as an index to : 1. — Erysipelas of scalp. 2. — Pediculosis of scalp. 3. — Syphilis. "Do not carelessly pass the fore-finger through the filthy blood-matted hair, and explore at once the depths of the wound to ascertain its nature." Shave, scrub, ascepticise. Do not mistake the depiessed centre of an ex- hi;ad. 163 , travasated blood clot, or congenital malformation, or atrophy, for depressed fracture ; or the sutures for a linear fracture. Never hesitate to explore, if you are uncertain as to whether the skull is depressed or not. Anaes- thetize ^nd perform whatever operation is neces- sary at once, i. e., as soon as the patient can be taken to a hospital. Always first examine for fracture of the vertex by sight. The indications for operation on the skull are : To prevent or remove infected tissues, to arrest bleeding, to remove the cause of compression, blood-clot, depressed bone or foreign matter, to provide for drainage, to prevent brain hernia. Blood can be wiped from a normal suture line, but not from a fissured fracture. Remember in trephining the skull that you are to consider the bone under your treatment to be the thinnest you have encountered, and thinner in one half of the circle than the other. Remember that the more a fracture of the skull 164 GOLDEN RULES OE SURGERY. approaches the punctured form the greater the need for elevation. Remember there never is uncertainty as to the proper treatment of gunshot-w^ounds of the skull in ordinary civil practice. They should be invari- ably operated on, the wound of entrance being al- ways comminuted and depressed. Never fret about the periosteum or pericran- ium. Sacrifice it without hesitation if you find it infected or torn, or lacerated beyond capability of repair. I have discarded large trephines and think that much more satisfactory work can be done with the smallest trephines and the Gigli saws. In most cases the chisel and rongeur will do all that is required. Always remember it is better policy to remove fragments of bone whose vitality is uncertain. Remember that injuries of the skull, when lim- ited to a small area, demand active treatment. If actual depression exists, whether the fracture be compound or not, operation is a necessity. HEAD. 165 Compound injuries of the skull indicate imme- diate operation. Never neglect to watch the temperature in com- pression. It is a more reliable guide in prognosis, than conditions of consciousness. [If the temper- ature be sub-normal and should subsequently' rise high, prognosis is bad]. Remember that the operation for the removal of fragments which have been pressing on the brain is rarely complete, spiculae being often left behind. Never undervalue the use of calomel in head injuries. The old experience still holds good that the physician who purges most of his patients has the best results and the largest practice. It took me twenty years to find this out, and let me say that calomel is not the only purgative. Castor oil and salts are better in most cases ; even the enema may suffice. The removal of the Gasserian ganglion is so serious an operation, its mortality so high, its re- sults so uncertain, even in the hands of good young surgeons (men over forty do not seem to perform the operation often), that I do not think it will be 166 GOLDEN RULES OE SURGERY. done so frequently in the future as it has been in the past. A case reported as successful, walked into the Lutheran hospital with return of tic in its worst form little more than ten months a»fter the ganglion had been removed(?). Always do peripheral neurectomies without the cranial cavity on the affected branches of the trig- eminus. The relief given will last for several years if long pieces of the nerve are resected, and may be permanent. These are beautiful surgical oper- ations requiring great skill and they neither put out an eye, nor do they kill. As a last resort the extirpation of the Gasserian ganglion may be done. I advise referring the cases to younger men who are well trained, who want the experience and who are glad to get big cases. The results will be likely to cool their enthusiasm. Brain tumors have become the objects of sur- gery in late years, and there have been some bril- liant results. But in the vast majority of cases the benefit to the patient is in no way up to the bril- liancy of the surgical achievement. Sometimes a little relief is derived from the mere elevation of portions of the skull. I have HEAD. 167 \ made blind patients see by elevating and removing a part of the frontal bone and large masses of un- derlying tumor and brain tissue. The benefit only lasted a few months when 'the headache and blind- ness returned. I consider any surgical operation which ofifers a reasonable chance to benefit the case, if only for a short time, justifiable. I am of the same opinion regarding operations in malignant tumors of other parts of the bod}^ as well, and this opinion will hold good as long as no better method of treatment is found. These desperate operations, however, should not be undertaken without having a full un- derstanding with the patient and his friends, and only after consultation with other members of the staff. An occasional life sa\'ed must be recompense for many fatal and discouraging results. The results of the treatment of cancer by the x-rays have been bad. Only in superficial epi- thelioma, where the red-hot iron would have done as well, have I seen benefit. In sarcoma I have seen some results that looked miraculous. But may they not have been gummata ? 168 GOLDEN RUIvES 0? SURGERY. HERNIA. Remember that no age is too young for a truss, and that no hernial pi-otrusion should be" without one. Never prescribe for a case of vomiting without enquiring about hernia and examining the abdom- inal rings. Do not diagnose a "strangulated" hernia in the male without first feeling for each testis, as inflam- mation of an undescended testicle often simulates strangulated bowel very closely. Always "explore" in cases of persistent vomit- ing if a "lump," however small, is found occupy- ing one of the abdominal rings and its nature is uncertain. Never be satisfied that the gut is reduced by taxis until you have put your finger fairly into and through the ring, nor until you have ascertained HERNIA. 169 by comparison of the two sides that no unnatural fulness is left. Remember that vomiting may continue after re- duction of gut by taxis, and be due to paralysis of the loop from its tight constriction, or it may be due to the hernia having been reduced en masse. Never be deceived by an opiate masking the acute symptoms of hernia, obstruction, peritonitis. Never procrastinate in strangulated hernia. It is the rule that the operation, if done promptly, will prove successful in herniotomy; the danger lies in your allowing the bowel to become irrecoverable. If you are in doubt, operate. Remember it is criminal to neglect a strangu- lated hernia — if you cannot reduce it, and dare not operate, hand the patient over to some one more competent. Do not hesitate to return the gut in herniotomy in all stages of disease short of gangrene. Use warm water to irrigate the gut and see it change from dark blue or black to red or pink be- fore you return it to the abdominal cavity. 170 GOLDEN RULES OP SURGERY. Do not hesitate to give a saline purge the day- after the operation, no matter how badly the bowel seemed to be injured. The same rule holds good after a resection and an end to end anastomosis. There is no danger of perforation or giving way of the suture as a result of the administration of castor oil or Epsom salts. But there i,s danger of high fever from autointoxication by the absorp- tion of foul intestinal contents and of death if the sewers are not promptly cleansed out after stran- gulation. Whenever possible let some form of radical cure operation follow the operation of her- niotomy. If not done at once it will have to be done later. The principle upon which the radical operation for the cure of hernia rests, may be stated as follows : Hernia takes its origin in the abdomen and is caused by' pressure from within the abdo- men; it must be cured by attacking the starting point. This is always the so-called inner ring. All operations or parts of operations upon the outer ring or the superficial parts of the inguinal canal are wrong in principle, and no matter how ingenious and beautiful the method, if it attacks the middle or outer layers of the abdominal wall, it HERNIA. 171 will be futile, a waste of energy and will fail in achieving a radical cure. The work that counts must be done on the ab- dominal wall just above the inner ring. The inner ring must be abolished. A neat and safe way to do this is by KochEr's new operation of inverting the sac. See the last edition of his operative sur- gery, the best book of its kind ever written. It gives a clear description of this simple method. Chas. Mayo also does this work at the inner ring high up on the abdomen and has realized the uselessness of work on the outer layers of muscle and fascia or the skin. I do not wish to be understood as advocating no suture of the middle and outer tissues. I think they should be brought together as neatly as possi- ble so as to get primary union. But I maintain that for the end of achieving radical cure this work is of very little aid to the stitches made high up which close the inner ring. Were it not for the pur- pose of rapid healing and avoiding suppuration the outer layers might be left to heal by granulation. Bernhardt, a former assistant of Kocher's, now the leading surgeon in the Engadine, in those 172 GOIvDEN RUIvES OF SURGERY. cases of large hernia in which it seems desirable en- tirely to close the inner ring, simply drops the tes- ticle into the abdomen, thus enabling him abso- lutely to obliterate the canal, by -having no sper- matic cord passing through the abdominal wall. Tht same object could be got at by castration, but might be objectionable to some patients. In the radical cure of umbilical hernia the best results follow the transverse incision and the over- lapping of broad, flat flaps of fascia, as published by W. H. Mayo. In these hernias there is no inner and outer ring. They are direct hernias and have practically but one ring. AWAY WITH "INFI.AMMA'TION." l7o 'Tf you would serve your brother, be- cause it is fit for you to serve him, do not take back your words when you find that prudent people do not commend you." — Ralph Waldo Emerson. "INFIyAMMATlON," AWAY WITH THE WORD AND THE CONFUSION IT HAS CAUSED. I have thought for many years that there is no real or genuine inflammation without infection. When the best pathologists like Ribbert,* Wei- GERT and Ehreich are in constant controversies and polemics about inflammation, what are we sur- geons to do about the problem ? Humbert declares, in his late publications, that there is no such tMng as parenchymatous iniiammation. They will probably all drop the time- honored but perplexing word, inflammation, and speak of it. in the literature of th; fature reverentially, as of a thing dead and buried. 174 GOLDEN RULES OE SURGERY. It is clear to all surgeons that between the pain- less and afebrile regeneration of injured tissues, and the restless, painful and febrile fight for exist- ence and restoration to health, there must be very many intermediate stages. In fact there must be all degrees of septic inf'^ction, up to the ones that end in death. Throwing all of these very different processes together seems to be the cause of the existing con- fusion. The mistake was made before we had any knowledge of infection and the term Inflammation was made to cover the whole. I know that it is more difficult to cure oM chronic and well established ills than acute fresh ones. After a long painstaking treatment has fail- ed, a radical operation is done as a last resort. I should like to propose that by comn-fon con- sent we drop the word inflammation. It has done some good, but has caused much confusion. Its various stages and its confounding definitions make of the word a cloudy notion and it seems unser- viceable. Let us extirpate it ! AWAY WITH "inflammation." 175 Inflammation and leucocytosis are looked upon as reactions by Ribbert;* who pronounces them as "under all circumstances defensive processes." He says that they are characteristic of increased normal life processes. A wound incised or punctured will heal by tis- sue regeneration and without pain unless infection intervenes. Infection causes Tissue-unrest; regeneration is thus nearly always interrupted and there is pain, etc. After the tissues have eliminated, absorbed or in some way disposed of the noxious unrest-pi"oduc- ing materials, be they bacteria, toxines or what not, regeneration again goes on to its normal end. If the tissues can not rul themselves of the sep- tic materials which produce fever and pain, the moist pack, or better, drainage by incision must .provide for their escape ; then again the healing pro- cess will be resumed, the unrest in the tissues is stopped and also the pain. *Biibert: Die Bedeutuna der Untzvndung—pubWsbed by Cohen, of Bonn, 1905. Brochure, price 35 cents. If Ribbert is correct, and I think he is, then inflammation must be com- pletely separated from infection, because the latter is always offensive, often deadly. It is certainly opposed to normal life processes. 170 GOLDEN RULES OE SURGERY. Let us substitute the simple, clear terms of in- fection and its concomitant tissue-unrest* for in- flammation. Away with inflammation! I feel as if this thought were in the surgical atmosphere and that it will be shared by many surgeons and also by many clear-headed pathologists who can break away from traditions, although hallowed by such names as Virchow, Cohnheim and others who worked before bacteria were recognized as the chief cause of infectious diseases. Let us separate the benign and defensive pro- cesses s4iarply and finally from the offensive ones. If the pathologists can not get along without in- flammation, I think we practitioners of surgery and medicine can, and with profit to our under- standing of disease. I am convinced that the process of regenera- tion, by which is meant the normal healing process, never goes beyond its object unless an infection in- tervenes. •This word (issue-unrest is used for the' first time In this little book. It seems to me to express exaitly what I mean. May it have a smooth passage and find favor in the eyes of students. AWAY WITH "INPXAMMATION." 177 The small round cell infiltration also never goes into febrile and suppurative processes iinless infection takfes place, whichimay produce the worst form of tissue-unrest and change a restful defen- sive process into a process of effusion, unrest, pain and fever. I propose that we separate Regeneration and Leucocytosis without fever, from Infection, Toxae- mia and Suppuration. (Sepsis.) The pathologists have mixed up these clear processes into the notion of inflammation. This subject is now and has al- ways been turbid, muddy, and therefore a favorite field for discussion at country medical meetings as well as at the centers of pathological science. The word inflammation makes for confusion. Away with it now and forever !* See general considera- tions, pages No. 59, 60, and 61. *"Der Mohr hat seine Schuldigkeit gethan, der Molir kmm neheii." Schiller's 'Fiasco." (The Moor has done his part, the Moor can go.) 178 GOLDEN RULES OP SURGERY. "MOIST DRESSING." There has been much discussion as to the rela- tive merits of the moist or dry dressing for wounds or incisions which appear to be clean or aseptic, and can therefore be completely closed by suture. Many maintain that after an aseptic operation in which the skin can be closed by sutures, a dry dressing will be the most appropriate and give the best result. I grant you that theoretically this is true, and that it works well in the majority of cases, but I maintain that it is impossible to say of any operation that it has been absolutely aseptic or that there will not be a stitch abscess or some other kind of an infection. This being the case, I favor the moist dressing in all cases, for the reason that under a moist dressing stitch abscesses or other superficial infections will be almost painless because the pus will be absorbed by the moist dressings into which it can escape. This is not the case if a dry dressing is used. The moist dressing "moist dressing." 179 will thus avoid much pain and many a change of dressings that would be needed under a dry dress- ing. Thp moist dressing is one that may be aseptic, wet by the use of sterile water or it may be as antiseptic as is desirable by, the use of antiseptic solutions. The moist dressing may be allowed to remain in situ as long as seems desirable, the only proviso being that its moisture or "wetness" be insured by the prevention of evaporation. This is the practically important point. Many wet dress- ings are applied carelessly and in a few hours be- come dry dressings. A properly applied wet dress- ing must remain wet any length of time required. To insure the indefinite moisture of a dressing a little care in the application of the rubber tissue oiled silk or other material which must cover each and every moist dressing is necessary. This consists in making sure that the impermeable oiled silk or rubber tissue is larger than the moisture bearing gauze, cotton or other poultice. If any part of the moist gauze protrudes, the dressing will not be moist long, because evaporation and osmo- sis soon dry it. 180 GOIvDEN RUI^S OF SURGERY. The greatest benefit of the moist dressing or antiseptic poultice as it has been called, is seen in cases of infection of the extremities, because in these localities rest by me3ns of splints or eten the plaster of Paris casts over and above a moist dressing can be given, thus insuring drainage and rest to the infected parts, the two cardinal indica- tions to be fulfilled in infections. A properly ap- plied dressing of this kind may be left untouched for a day, a week, or a month, or even longer. I have often applied this kind of dressing to a crushed limb, a compound comminuted fracture, and have allowed it to remain for six weeks or un- til union was complete. It is true that in some of these (iases the dressings when removed were often very odoriferous, but the patients had made afebrile, satisfactory recoveries, the odor being due to saprophytic or non-pyogenic bacteria. The wounds having been perfectly drained were found granulating as normally as if they had been dress- ed every day. MOUTH. 181 MOUTH. Do not leave hare-lip pins in hare-lip operation, (if you use them), longer than forty-eight hours. Your plastic operations on the lips will do better by using fiine thread or catgut than the old-fash- ioned needles. The use of needles is rapidly pass- ing. Remove sutures early. By needles I mean insect needles or long pins. Always stop to guard your thumbs before you reduce a dislocation of the jaw. Always use blunt scissors in operating on the fraenum linguae. Do not forget in ranulae to search for stone in the duct. Never think lightly of any ulcer on the tongue or lips of a patient after middle life. The differential diagnosis between syphilis and 182 GOU>EN RULES OE SURGERY. malignant disease of tongue, floor of the mouth, jaws and pharynx is difficult. Always try an anti- syphilitic course of treatment, together with local measures before making a radical extirpation. Four or six weeks will suffice to exclude lues. Always look for bad teeth and send the patient to a good dentist before you begin your treatment. Many cases of stomach disease are due to decayed and defective teeth. The old rule, upper lip syphilis, lower lip epithe- lioma, will not always do. , NOSE. 183 NOSE In nose bleeding of a serious nature or long duration, don't fool away time with ergot, adren- alin or other medicines. Plug the nose and do so efifectively. Always suspect a foul discharge in a child to result from a foreign body, if the discharge be from one nostril. Never neglect the mouth ligatures of the plugs for the posterior nares. It is difificult to remove these plugs without them. Never forget to look for Meyers' pharyngeal tonsil in mouth breathers. Its removal is one of the most satisfactory surgical operations. Nil nocere should be the motto of every spec- ialist who finds "spurs" in many peoples noses and saws or gouges them away. Scars on the mu- cous membrane in the nose are covered by scabs, 184 Gou)EN ruIve;s of surgery. and are often troublesome for years. The same .motto is also very much to be recommended to G. U. men who do internal urethrotomy for stricture and gynaecologists who think every woman ought to be curetted annually, as vyell as to other spec- ialists and general practitioners; and last but not least let surgeons keep the old motto always in mind. OESOPHAGUS. 185 OESOPHAGUS. Never forget that when a foreign body, though only of moderate size, has become fixed in the commencement of the oesophagus or the pharnyx, and has resisted a fair trial for its extraction or dis- placement, an incision, (pharyngotomy), etc., should be made at once and the foreign body should be removed, although no urgent symptoms are present. Never omit to exclude aneurysm of the aorta before you pass a bougie for supposed stricture of the oesophagus. Never use force in passing a bougie through any oesophageal structure, certainly never in ma- lignant stricture or where there is any suspicion of aneurysm. Remember catgut sutures are used for wounds of oesophagus;- never silk or silver. 186 GOIJDEN RUIZES OF SURGERY. Always be certain that your tube enters the oesophagus in using the stomach pump (especially if the patient be under chloroform, comatose, or drunk.) [Cases are recorded in which beef tea, plaster of Paris, and other fluids have been injected into the lungs with fatal results]. Oesophagotomy is easy, if the surgeon can make the tube bulge on the neck by using a large sterile male catheter introduced per os. Stricture of the oesophagus caused by swallow- ing concentrated lye kills about two-thirds of the children to whom this accident happens. The other third survive with strictures of various por- tions of the gullet and pharynx due to cicatricial contractions of all degrees, up to complete closure of the passage. In many of these cases life is saved by feeding through an artificial opening into the stomach made by the operation of gastrostomy. In a case of this kind a child was kept alive, but was puny, weighing only 19 pound^ at the age of 6j/2 years. She had been kept alive four years by feeding through the artificial fistula leading into the stomach, but was evidently growing weaker all the time. No doubt the mucous membrane of the OESOPHAGUS. 187 stomach was partially cauterized away, and the fistula was leaking constantly and was not working satisfactorily. Death would surely have ensued if the condition had not been remedied. Not even the finest bougie could be passed, nor could colored fluid or milk be injected either up- wards or downwards through the stricture. Un- der these circumstances I determined to attempt forcing a passage throvigh the posterior medias- tinum. As a preparatory operation I made an oesoph- agotomy at the root of the neck, thus shortening the distance from the oesophageal opening in the stomach to a point just above the manubrium sterni. My intention was to bore a hole with a tro- car-pointed instrument through the posterior med- iastinum, and below follows a description of what I found and did. I shudder even today at the fear- ful chances I took to save a life. When it is re- called that in the dark, the trocar had to pass through cicatricial, irregular masses of tissue in close relation to the arch of the aorta, the left common carotid, the thoracic duct, the two pneu- mogastric nerves and many other important struc- tures, among them many thin walled veins, the pos- 188 GOLDEN RULES OF SURGERY. terior wall of the trachea, etc., the hazardous, na- ture of this operation may be appreciated. I am told that Prop. Warren cited this operation to a class of his students at Harvard medical school as among the most daring ever undertaken. I am sure I have never done one that was more uncer- tain in its outcome. I am glad to report that the pa:tient's weight increased from 19 to 42 pounds in a short time after the operation was done. I am told that she still uses bougies, but has become a fairly healthy young lady. Second Operation. — Three weeks after the first operation a second one was performed for the re- duction of the stricture, which was now much more accessible, the patient's condition being about as good as when first operated upon. When she had been chloroformed, the end of a soft rubber tube, whose other extremity was attached to a Da- vidson's syringe, was passed through the epigas- tric fistula into the gastric opening of the oesopha- gus. Pressure was applied to the bulb, but no water appeared at the fistulous opening in the neck. All attempts to inject water through the stricture from either side had utterly failed. A pillow was OESOPHAGUS. 189 placed under the shoulders and the neck put upon the stretch. The index finger was introduced into the oeso- phagus through the opening in the neck, a soft metal bougie being at the same time passed into the lower portion through the cardiac orifice; at first the end of the bougie could not be felt by the examining finger, and much careful manipulation was necessary before it could be positively deter- mined. The uncomfortable proximity of. impor- tant vessels precluded the use of any cutting in- strument. The pewter or block tin bougie was then removed and its end cut to a trocar point with a scalpel and reinserted as before ; when located, gentle manipulation was made against its point through the stricture by the index finger in the oesophagus, a rotary movement being simultane- ously given to the bougie. In this manner the stricture was successfully perforated;, the bougie passed upwacd to the opening in the neck, where a stout double silk ligature was attached to its end and drawn down through the oesophagus and out of the artificial opening in the stomach. Upon this ligature there was threaded through its lumen a Nelaton rubber catheter of an external diameter 190 GOI.DEN RUIvES Olf SURGllRY. of 1.5 centimeters; this was drawn through the oesophagus until the upper end had entered the neck, and then pushed upward until the upper end could be seized in the pharynx and drawn forward out of the mouth; both ends of the catheter were now outside of the patient's body; they were su- tured to the ligature, the ends of which were tied together. The after treatment was troublesome and it was not easy to keep open the passage. In order to keep it open regular, continued use of bougies was necessary. Without their use the canal would surely have closed. See New York Med. Journal, Vol. 1895 for details. I have often been asked by students and phy- sicians what operation during my long experience I considered as the greatest and the one requiring most "nerve." I always answer that a surgeon who operates on his nerve is a dangerous man and not well qualified. The quality called "nerve" by Americans and English should not be required, in fact is not a valuable asset in a well-educated sur- geon. However, let us remember that it takes a lot of nerve even to puncture the pleural cavity or to make an abdominal puncture or tapping op- OESOPHAGUS. 191 eration in a case of dropsy if the surgeon has not the anatomical and physiological training. Nerve is valuable to a surgeon if it means courage to do his duty, which he has recognized after exhausting all scientific methods of diagnosis and after his judgment says : Take the risk because it seems likely to prolong or save a life or to palliate other- wise fatal disease. In the above case my judgment was proven to be correct and my courage rewarded by the favorable outcome of the case. I have never had one requiring more "nerve." 192 GOLDEN RULES OFSURGERY. OPERATIONS. Remember that "surgical cleanliness is more than ordinary cleanliness." Have plenty of assistance, but not too many as- sistants. Never permit a naked light to be brought near the ether apparatus when anaesthetising. Be sure that nurses are reliably trained in asep- sis. Never neglect in all operations which will pro- duce a shock to the urinary system, e. g., varico- cele, fistula, piles, radical cure of hernia, to ascer- tain before the operation, if the urethral canal be without stricture. [Sometimes stricture is encoun- tered in relieving retention after such operations, and you may be unprepared for the obstruction.] I approve of spectators, but they must obey OPERATIONS. 193 rules that are made to insure cleanliness and avoid dangers. Never neglect to examine the lungs for phthisis in all cases of ischio-rectal disease and fistula in ano. Always see that the end of the plug or drain is properly secured, in inserting plugs or plug-appli- ances for colotomy and gastrostomy; or drainage tubes for abscesses or wounds, especially in empy- emata. Never operate without first examining the urine for albumin and sugar, but do not, in these aseptic days, be scared about either, if the operation be a necessity. ' Remember cases of jaundice and those with dis- ease of spleen are unfavorable subjects for opera- tion. Never apply an elastic (Esmarch) bandage to render a limb bloodless if tuberculosis or growth or gangrene is present. Elevate the limb, stroke it, and apply the Esmarch rope. (LiST^R.) Never forget a patient's age in years is not the 194 GOIJDEN RUIvI^ Off SURGERY. index to his "vis" or "last." Vide Errors in the Chronometry of Life, Paget, Studies of Old Case Books. Read : Paget on Surgical Disasters and Hilton on Rest and Pain, buy Senn's Principles of Sur- gery and Kocher's Operative Surgery. The latter is not an ordinary text-book, but is based on KocH- Er's own work. He recommends nothing unless he himself has found it to be useful in practice. Un- fortunately I can not recommend a text-book cov- ering the whole of systematic surgery because no one man has written a book which will be found equally good in all parts. Where a system of sur- gery is written by many different authors and. con- tributors, there are always some weak and care- lessly written chapters, partaking of the nature of compilations, made without research or large ex- perience on the writer's part. Men try to do too much and are often persuaded by publishers and prompted by a desire or a promise to make money. College professors are apt Lo write books knowing that their students will buy them. Let the stu- dents buy them, but don't you. Never forget that the surgeon who neglects to OPERATIONS. 195 suture a divided nerve or tendon commits the same mistake as he who neglects to reduce a frac- ture. [Use an ordinary sewing needle, with a round point, for nerves]. Never forget the tripod of successful healing of wounds has three legs — asepticism — rest — coapta- tion of edges. Never forget that if an operation wound suppu- rates, the fault lies with the operator or his as- sistants. Remember that mercury perchloride gauze or lotion ruins steel instruments. Rapidity is a desirable quality in an operator for more reasons than one ; the quicker the opera- tion is finished the shorter will be the time of the narcosis, a great advantage for the patient ; still let there be no lack of exactness and of artistic finish. " The neatness of the dissection will be greatly enhanced by the free use of retractors for the pur- pose of exposing the field. A good operator rec- ognizing the anatomical structures will work by 196 goi,de;n rules of surgery. layers and I advise using the fingers and scissors more than the knife after the skin-incisions. A bad anatomist can be a reckless butcher, but not an artistic surgeon. Remember that an intimate knowledge of the physiology of respiration, of circulation and of bloOd pressure are as necessary to make a success- ful operator as is anatomy. This may sound par- adoxical, but I never fail to impress upon my stu- dents the great value of operations and vivisections on large dogs. PEivVis. 197 PELVIS. Remember in extravasation of blood beneath the gluteal fascia there is rarely any bruise or sign of injury to the skin. Do not mistake such for an abscess. Never forget to determine the absence of a for- eign body in buttock wounds. Always ligature a bleeding vessel in the but- tock at once, even at the risk of a deep dissection. Do not carry out passive movements very ac- tively in fracture of the true pelvis in order, to elicit crepitus. Remember the serious consequences which may ensue from the displacement of a pointed fragment. Never omit to empty the bladder (if the patient cannot) in cases of falls on the buttocks, fractured pelvis, blows on the belly, etc. 198 GOLDEN RUIvES OF SURGERY. In many of the headaches and pelvic aches of women, purgation actually cures. Retroflexions of the uterus are not often indi- cations for surgical interference. RECTUM. 199 RECTUM. Never forget in fistula in ano to eliminate for- eign body, ulceration, stricture, and malignant dis- ease of the rectum. Never forget that constipation alternating with diarrhoea renders a_ rectal examination for stric- ture imperative. Remember the saying, "No internal opening to a fistula, or a blind fistula, is usually a blind sur- geon." Do not forget the probable need for a catheter after an operation on the rectum. A patient who thinks he has piles may have something quite different. An enema followed by an examination will permit you to make a diag- nosis in some cases, in others anaesthesia will be necessary. 200 GOLDEN RUIZES OF SURGERY. SHOCK. Never forget in shock and collapse that the es- sence of successful treatment is to obtain time for your patient to rally. Keep the heart going, but do not trade on its exhausted power; maintain its action, do not force it. Do not resort to strychnine, digitalis and other poisons, but if you must inject something, try a syringeful of ether ; if you will give poisons, give them before the heart and diaphragm are too weak to stand the dose. Many patients are killed in shock by the syringe. Some survive in spite of the poisons that are used, but I have never seen one benefited by them. Remember that minimum doses suffice to kill a patient in shock after an operation, or after a loss of blood. Warmth applied to the surfaces, salt solution SHOCK. 201 infused, liberal rubbing, artificial respiration and similar therapy are helpful; electric stimulation lowering the head and elevation of the legs are often called for, but hypodermic use of poisons, is not permitted in my service. I would have the tablets and syringe barred from the operating room. I would rather honestly sign a certificate : death from "shock, following operation," than doubtingly write those words after a lot of poisons, two, three or four different kinds, had been shot into a moribund patient by a scared lot of surgeons, assistants and nurses. 202 GOI.DEN RUtES OS SURGERY. - SPINE. Never forget that in fracture of the spine the tendency to death is due to pneumonia and com- plications, if the fracture is situated high up; and to urinary inflammation and bedsore, if lower down. Of 500 cases operated on by laminectomy or some other operation for the purpose of releasing the compressed cord, one half survived. Of three hundred cases with more definite his- tories only twenty-nine per cent, were restored to health. But you must remember the unreliability of statistics in surgery. Always have a careful neu- rological diagnosis before deciding to operate. Never forget the atonic bladder or the back, devoid of the sense of feeling. SPINE. 203 Do not be content with merely washing the red rubber catheter each time you Use it. Let it be kept in carboHc lotion. Remember also that the urethra is insensitive, and that the catheter must be introduced with double care and treble gentleness. Never neglect to see for yourself that the patient's back is kept cle^n, dry and well protected from prolonged pressure. Assistants and nurses usually do their duties, but see for yourself. Never puncture a spina bifida in the median line, always at the side, taking in the skin; avoid air, and close puncture securely. Spina bifida may often be safely removed if the surgeon is expert and aseptic. Never suspend by the head alone in adjusting a Sayre's jacket for a Pott's curvature of the spine ; let the toes and armpits help to support the weight. Never forget how easily pressure sore or ec- zema occurs under a badly padded or dirty plaster of Paris jacket. It is better to remove it more often than have this happen. 204 GOW>EN RUIvES OF SURGERY. Never forget that the earlier stages of caries are often unaccompanied by any decided symp- toms. When curvature exists there is no longer room for doubt, but do not wait for curvature. Never permit a patient v^^ho has sustained any injury to the back to quit the casualty department* until he has passed water. [Bloody urine will shbw at once that the kidney has been injured]. *Emergency ward. STOMACH AND INTESTINES. 205 STOMACH AND INTES'TINES. Our operations for cancer of the stomach have been unsuccessful if we refer to a radical cure of- the disease. Very few permanent cures are record- ed. Cancer of the stomach is so very common and causes so much distress that these cases will al- ways continue to apply for relief. Our only hope of ever curing cancer of the stomach lies in early diagnosis. It is probably true that there is a pre- cancerous ulcer in most cases and if this stage >" diagnosed and treated by a drainage operation the ulcer will heal up, and a cancer be avoided. Many lives can be saved by an early gastro-enterostomy or gastro-duodenostomy if only the operation be done during the early stage of an ulcer. As long as the medical treatment of cancer shows a mortality of one hundred per cent, it is clearly the duty of the internist to refer cases which resist his treatment and in which the well 206 GOIjDEN RULES OF SURGEKY. posted physician must suspect malignancy, to a surgeon as early as possible. A look into the future seems to indicate that the medical man must become a scientific patho- logist and diagnostician if he would rise above the level of the charlatan. The function from which he will derive most glory and most income, because it will be the most beneficial to the patients, will be the timely calling of an operator. It will be a dis- tinct step forward, if the internist will be as ready to prescribe a surgeon for his cases as he has been to prescribe morphine or other drug in the past. The public will learn to appreciate this service and to pay for it gratefully, if only the surgeon be honest and unselfish enough to say to the patient upon whom he has successfully operated: "You owe your life to your physician, who so skillfully recognized the danger you were in." Few ulcers make diagnosable symptoms unless they are indurated. Their symptoms are of the kind which indicate stenosis at the pylorus and ob- structed drainage of the food from the stomach into the duodenum or from the duodenum into the je- junum. I have seen painful pyloric spasms in some STOMACH AND INTE^STINES. 207 of these cases and regard this symptom as of great value in making a diagnosis of ulcer. These spasms last from a few minutes to an hour and are very painful. They not only involve the pyloric ring in the painful contraction but the entire py- loric end of the stomach is involved as I have been able clearly to prove in several cases occurring in medical men and other very intelligent patients fa- miliar with the anatomy of the stomach. It is clear to my mind that only this early drainage operation of the stomach will ever succeed in curing or rather avoiding cancer of the stomach. Operations of resection of parts or the whole of the stomach are usually fatal or at best only prolong life for a short time. The best result I have ever had, was that of a woman from whom I removed the pyloric half of the stomach who now lives in fine health, more than four years after the resection. All my other cases of resection, amount- ing to fifty-eight in all, died of cancer in less than three years. Sorhe of them were relieved, and even gained weight for months, but all eventually succumbed to the disease, eleven died of shock. This experience accounts for my pessimism as re- 208 GOLDEN RUIvi:S OP SURGERY. gards radical cure of cancer of the stomach by surgical operation. The successful surgery of the stomach is con- fined to cases of benign or precancerous ulcers, and has been much to the front for about two years. The operation which gives us our most pleasing results is gastro-enterostomy above referred to, and in this short treatise I can only give a few rules which can be followed with safety. Remember to make the anastomosis between the stomach and the intestine so as completely to drain the foi'mer and to give the ulcer physiologi- cal rest, under which it will nearly always heal, if benign. Remember that the so-called vicious circle can be avoided by Kocher's gastro-duodenostomy or by gastro-jejunostomy without a loop. Make the anastomosis not more than three or four inches be- low the duodenum in the first part of the jejunum so as to avoid a loop. I made a posterior gastro-enterostomy and found that the indurated ulcer which extended into the pancreas failed to heal. We can not promise STOMACH AND INTESTINES. 209 to cure every case. The resection of the ulcer itself (of course I am speaking only of benign ul- cers), may prove to be the only method of radical cure in some rare cases. I once resected a tumor (the microscopical ex- amination failed clearly to establish malignancy), of the pancreas the size of a small hen's egg. In doing so I cut the duct of Wirsung. I did the thing that occurred to me at the time of the emergency. I split open a neighboring loop of jejunum and stitched the edges to the pancreas in such a man- ner that all of the wound in the pancreas opened into the gut. The patient, a woman of 70 years, in whom I had diagnosed pyloric cancer and was in- tending to resect, lived six weeks. An autopsy was" refused and the cause of death in the absoence of a more definite diagnosis was given as exhaus- tion. Operations for the removal of foreign bodies from the stomach by gastrostomy are among the easiest in surgery and are successful. Remember that the establishment of a gastric fistula is to be done by either WiTzEiv's, Marwe- 210 golde;n rui^s of surgery. del's or Frank's method or some modification of those named, as may be indicated by the object to be achieved. Remember that the Murphy button and other similar contrivances are no longer used by those who can make an anastomosis with a needle and thread. These mechanical contrivances as well as the elastic ligature,* which I gave up twenty years • ago, should no longer be used for making intesti- naPanastomoses except in cases where a rapid op- eration on a dying patient seems indicated. Before operating on the stomach have it thor- oughly washed and leave a stomach tube in it dur- ing the operation if possible. Suture of intestines is an art which though not difficult to execute and not at all dangerous in itself, requires close attention to detail. The one principle underlying this manipulation is the ap- preciation of the physiological fact that serosa will *Over twenty years ago at a meeting of the Tri-state Medical Society, I reported this method of making gastroenterostomy and other anastomoses, but I found it a bad,. unsurgical operation, even worse than the button. It now bears the name of an honorable colleague and has been used by surgeons with some degree of success, but I cannot concur in its recommenda- tion. The elastic ligature and the button will be abandoned by young, skill- ful operators. Old men who have used these devices will, of coujse, continue to use them. STOMACH AND INTESTINES. 211 adhere to serosa by mere contact provided that the two surfaces are sHghtly irritated and are kept in contact long enough for the formation of organ- ized" tissue. This process is called primary union and is accomplished with surprising rapidity. The interposition of epithelial tssue between the two serosas while the sutures are introduced is the main thing to be avoided. One line of sutures may be buried by a second and the second by a third, as may seem requisite to insure strength and safety. The hundreds of different suture methods which have been invented all depend upon the above mentioned quality of the serosa and must be studied and tested by the surgeon. Then he can cli,oose the method with which he is successful and which suits his personal abilities and his own views of their efficiency. Some methods appeal to and are used with success by one surgeon, while other sui-geons succeed equally well with other methods, so that I am constrained to advise young surgeons to try them all before making up their minds as to their relative merits or demerits. The above applies to both end to end and lateral suture of intestines to each other. I have found it a good rule never to judge of a method until I have tried 212 GOLDEN RULES OF SURGERY. it myself. A priori verdicts or opinions are always unreliable, often false and misleading. The treatment of intestinal obstruction can not be satisfactorily explained in a small work of this kind, and again I can only give you the principles on which to act. If called to a case early have patient taken to a hospital with all conveniences and make an explo- rative section and follow this up with a radical re- moval of the obstruction. In all other cases, in which the patient has been medically treated until there is peritonitis, tympan- ites, faecal vomiting, etc., make one or more intes- tinal fistulae or artificial anus. Secondary opera- tion will be indicated later on if the patient's life be saved by the intestinal .fistulae which have been established. Lateral anastomosis has its greatest usefulness where intestines of unequal caliber are to be joined. Under such circumstances end to end an- astomosis is difificult. THROAT. 213 THROAT. Never neglect or think lightly of a stab wound of the neck. Remember that in stab wounds of the upper part of the neck with arterial bleeding, there is an impossibility in many cases of determining what is the exact source of the haemorrhage, so numerous are the great vessels in that region. Apply a lig- ature to common carotid or external carotid if un- controllable. Never neglect in cut throats where the trachea has been opened, to remove all small fragments which hang loose in the trachea, or they may swell and eventually stop respiration. Avoid skin sutures in cut throat when the wind pipe is opened; always suture trachea, but the skin wound may be left to granulate; if muscles and 214 GOLDEN RULES OF SURGERY. fasciae are cut some catgut sutures will do no harm and may hasten the healing process. Never put silk or silver ligatures into a wound- ed oesophagus; only use catgut. Never forget that fractures of the laryngeal car- tilages are serious injuries. The nearer the cords, the acuter the symptoms, the more decisive must be the treatment. If the fragments are displaced and the mucous membrane lacerated or perforated by the fragments (as testified by emphysema and blood spitting), tracheotomy must be performed immediately. Remember that tracheotomy and insertion. of the tube is especially necessary in wounded epiglot- tis or arytenoid cartilages. Never neglect in cases of dysphagia or violent dyspnoea in infancy, to examine the pharnyx for retro-pharyngeal abscess. Never neglect in all sudden dyspnoea in a child to pass your finger into the upper part of the larnyx to search for a foreign body. Sanction no delay in removing a foreign body THROAT. 215 known to be in the larynx. Invert under anaes- thesia and if the body does not come away, do laryngotomy or tracheotomy. I have had to ex- tract foreign bodies from 'the bronchi below the bifurcation, when this rule was neglected, months after the accident. Never invert in cases of foreign body in the trachea, unless you have your tracheotomy instru- ments ready, for the danger of instant suffocation through lodging of the foreign body in the glottis is great. Never hesitate in foreign bodies in the trachea to invert the patient after the tracheal incision has been made for the extraction of the foreign body. Never use forceps, but invert and succuss the pa- tient, or use a hook, bent probe, or wire snare. Never forget that lung disease invariably ensues on the retention of a foreign body in the bronchus. Always keep' the tracheotomy instruments by the bedside in cases of oedema of glottis due to syphilis, erysipelas, wounds, and especially scalds of glottis. 216 Gou)EN rui.es oE surgery. Always secure your tracheotomy tube by knot- ting the tape. Little patients are apt to drag at and undo a bow. If the tube slips out and nurse is not present or handy at replacing it, a fatal re- sult may ensue. Either use the solid double tube or sew the trachea to the skin, so that breathing without a tube is free and easy in an emergency, where a tube can not be had. Remember the "lines of safety" for dividing fascia of neck, in dealing with cellulitis of neck : 1. — Mesial line from chin to interclavicular notch. 2. — Line along posterior border of sterno- cleido-mastoid, taking care to avoid the ex- ternal jugular vein. 3. — Where there is a fluctuating, bulging ab- scess, it may be opened at its most promi- inent point, using the ordinary precautions. VEINS. 217 VEINS. Do not excise or underpin a varicose vein if there is any suspicion of phlebitis, or if th«re is any inflamed condition of the area drained by the vein [e. g., inflamed ulcer of leg, with varicose vein]. I favor the excision of varicose veins if they become large and painful, after the method prac- tised by C. H. Mayo. The operation is extensive and is successful in the hands of skillful men and under thoroughly aseptic surroundings. Where you have the least doubt or lack of confidence in the cleanliness of the surroundings, do not operate. This rule applies to all operations as a matter of course, but I repeat it in this connection, because the removal of the varicose saphena vein opens up a vast field of lymphatics. Remember that all veins are surrounded by a very complete netw^ork 218 GOLDEN RULES OE SURGERY. of lymph channels and capillaries, in which strepto and staphylococci and other germs are very prone to thrive and rapidly to cause febrile and septic dis- turbances and death. REMINISCENCES. 219 REMINISCENCES. When not yet eighteen years old, having ac- quired an American college education and the de- gree of B. A., I matriculated at the University of Heidelberg in 1872. After two years of study in anatomy, physiology, chemistry and histology, all practically laboratory work and dissection, I began the study of medicine and surgery. I had become enamored of anatomy and embryology, and the advent of Gegenbaur, the then greatest living morphologist, and EueRBRINGER, his prosec- tor, from the University of Jena, bringing with them the gospel of Darwinism and evolution, kept me in touch with biological science and its en- lightening influence on dry old anatomy. Under Gegenbaur anatomy took on a new in- terest, and under his guidance and in his labora- tory I began morphological work, which ended in my taking an embryological subject for my the- 220 GOLDEN RULES OE SURGER'^ sis. The results of my investigation turned out to the satisfaction of Gegenbaur and my thesis re- ceived the highest honors from the faculty, and in the final examination for the degree of M. D., I was awarded the summa cum Umde. It was my intention to become an anatomist, to take up the academic career, but my father, who was a physician, said, "You must become a sur- geon if you wish to locate in America. An anat- omist cannot make a living in our country." The great surgeon, Gustav Simon, who made the first kidney extirpation, was the leading sur- geon and held daily clinics at the academic hos- pital. I soon became a favorite with him because of my accurate anatomical acquirements, my abil- ity to draw with pencil and chalk and my con- genital dexterity. In the summer of 1875 Mr. Joseph Lister came to Heidelberg staying a few days and himself showed us his antiseptic method and its technique, the carbolic spray, the protective silk, etc. One of the first cases upon which we used it was a com- pound comminuted fracture of the leg just below the knee. It healed almost without rise of tem- perature and without pus in a way that appeared REMINISCENCES. 221 to us a miracle. Most compound fractures, in fact most amputations in those days, had chills and fever and died of septicaemia. The results of Listerism for some years did not come up to expectations in the dirty old academic hospital, where we used sponges and where the attendants and nurses were not yet trained in antiseptics. A very heated con- troversy between surgeons pro and con took place. The majority of surgeons remained sceptical, but there were some who had new hospitals and re- ported results so much better than the old results that, of course, all were compelled to take up anti- septic methods. The Germans soon became con- vinced of the truth of the doctrine and finally went a step farther and introduced the aseptic method of operating and of wound-treatment under which we are all working now. This method is applica- ble to all clean cases and even to infected ones, if only rest is secured, by free drainage. I claim that the worst form of unrest is caused by bacteria and their toxines in the tissues. The term inflam- mation no doubt was useful, but it now is only confusing and the notion of infection together with the tissue-unrest it. produces would be a much bet- ter form of expression and I have here proposed it. 222 GOLDEN RULES OE SURGERY. There is no reason why we must get all our the- ories o\ fever, infection, toxaemia, etc., from for- eigners. If I were not a busy operating surgeon, I would take the time and do the work to establish my view and rid the profession of the time-honored and misleading word inflammation. During the summer of 1876 I became an in- terne in the academic hospital, on the male divis- ion, and received the magnificent salary of fifty- two marks and some pennies, which were brought to me on the first of each month by a university or government official. Besides I had a large room and bedroom, first-class fare and a bottle of claret per diem. My. associates were the other assistants, all of them now holding the highest honor-positions the medical profession affords in Europe. This position did not last many months because Simon died during the year 1876 of an aneurysm of the thoracic aorta. On the day when it btirst, the poor fellow, honored and loved by us all, becoming dys- pnoeic, as the blood sickered out of the sac, com- pressing the lungs or bronchi, sent over to the hos- pital to have tracheotomy done, thinking it would relieve him. Henry Braun was first assistant, and although convinced of the uselessness of the oper- REMINISCENCES. 223 ation, performed it under gceat difficulties, the veins of the neck, being enormously distended. Marion Sims, whom I met while I was Simon's as- sistant, says in his obituary (American Journal of Obstetrics, 1876) : "The propriety of withholding from such a man the gravity of his disease seems to me questionable." Had' he known he might have lived a little longer, he would have done less work. Which is the better? Of course he would not have undergone the tracheotomy which he insisted on having done without an anaesthetic. After the canula was introduced he declared him- self relieved, his pulse kept up until 10 o'clock, then he collapsed. Thus passed away one of the great lights of surgery. I owe him my introduction to surgery and more thanks than I can ever express. He showed me how to close vesico-vaginal fistulas, and he did it better than any man then living. I think that possibly now Howard Keli,y can do it as well as he could. He showed me how to do plastic work on the face and he could use a needle and fine silk more efifectually than any surgeon I ever saw put in sutures. His wounds looked neat when closed and he got first intention in his plastic work very 224 GOLDEN RULES OF SURGERY. frequently without antiseptics, because he was nat- urally a clean man. After Simon's death I remained at the hospital a few months longer as an assistant to Lossen who during the interim filled the chair until Czerny was called and a new hospital built. Bearing letters of introduction to von Lang- ENBECK, that prince of surgeons, I went to Berlin in October, 1876, and was soon installed as a pri- vate student of v. Langenbeck's. This man was undoubtedly the quickest and neatest operator of his generation, and not only that, he was also one of the most amiable and polite gentlemen in Eu- rope. So great was his reputation that he opera- ted on members of the Russian and English reign- ing houses. He made annual trips to England and spoke the English language very well. He gave a small class of us instruction in surgery on the cad- aver. One day he said to me : "A Scotchman, named Alexander Ogston, has invented a peculiar opera- tion for knock knees, a sort of subcutaneous oste- otomy of the internal condyle of the femur. Will you read it up and show it to us tomorrow morn- ing on the cadaver?" I did the operation on the cadaver the next mqrning at his course which he REMINISCI^NCES. 225 gave at six o'clock A. M. He complimented me before the class on the manner in which I did the work. He was president of the, German Society for Surgeons and was always re-elected by acclama- tion. He proposed me as a member and invited me to a dinner he gave at his home to the execu- tive council and foreign guests. I was the young- est of his guests. Dr. Fred Dennis, of New York, was also at the dinner, and speaking of that now celebrated surgeon, I may say it was his ad- vice to me which resulted in my going to England and taking the examination at the Royal College of Surgeons in London in '77 . To Langenbeck I owe what I know about ele- gant and rapid operating, and also about the cure of cleft palate and complicated harelip as well as about some neurectomies and plastic operations on the eyelids and lips, but most particularly he had tis practice subperiosteal resections. If I were to describe some of the feats I saw him do they would not be believed by many who did not see him operate. I will relate two surgical tricks he did in one day. He incised the perineum and ex- tracted a large stone from the bladder in one min- 226 GOIvDEN RULES OP SURGERY. ute. Next he exarticulated at the hip in sixteen seconds. I mean the limb was carried out by the attendant after sixteen seconds. It must be re- membered that he learned to, operate from his un- cle in the days before they had anaesthetics. He related of one of his hip exarticulations done on a strong young soldier who was shot through the hip joint, that the fellow jumped out of bed and , hopped after a nurse the third day after the oper- ation, trying to kiss her. Langenbeck's aristocratic manner and extreme politeness prevented undue familiarity, but he made us feel that he was our teacher and our friend upon whom we could rely for any act of friendship. I intended going to take a course under Bill- ROTH at Vienna, but upon making my farewell visit to VON Langenbeck, he persuaded me to take a letter to the commanding general and to the chief surgeons of the Russian army who were then, in 1877, fighting the Turks. In the letter he recbm- mended me as peculiarly fit to be the chief of a field-hospital. Before I could reach the seat of war, however, peace was concluded, so that after all I could take a short course in surgery from Billroth in Vienna who was just then doing all his REMINISCENCliS. 227 work under the spray. His results were pretty good, but I did not get much out of this great man, although he was kind enough to invite me to his laparotomies, which in those days were not every day occurrences. I remained in Vienna only about three and a half months. From there I returned to Heidel.berg and made an anatomical investigation of the knee- joint and studied the embryology of joints in gen- eral under Gegenbaur. This memoir is published in the M or photo gisches Jahresbuch of 1878 and contains but little that is of practical interest, but is considered of scientific importance. The Wash- ington University of St. Louis has acquired a com- plete set of this periodical recently and any one in- terested can see the contribution there. After a delightful time of a few months of intense embryo- logical work spiced by the association with some of the leading scientists from all parts of the earth at- tracted to Heidelberg by the name of Gegenbaur, I went to London for the examen. They know how to mix research work and social recreation in European scientific workshops. Many of the workers are very poor, living on a mere pittance, but they all save enough out of their incomes, be 228 GOLDElJ RULES OF SURGERY. they ever so small, to take daily recreation, walk- ing about the mountains and having a glass of milk or beer with a sandwich at rural inns. In London I found the hospitals and medical schools in every way behind the German institu- tions and had the feeling that in histology, pathol- ogy and embryology the examiners were sadly lacking in the scientific, though well up in the prac- tical aspects of their various subjects. In antisep- tics even, though we look upon LiSTER as the foun- der and originator of the antiseptic wound-treat- ment, the Germans are the ones who have devel- oped and perfected the method and have given the scientific basis as well as practical usefulness to it. The one very pleasant recollection of the Lon- don term which sparkles even now after thirty years is an evening I spent in St. John's Wood at Mr. Huxley's house in his charming family circle. After I had spent about an hour talking about Gegenbaur and HaeckEE and the work at Heidel- berg, who should walk in but Mr. Chas. Darwin leaning on the arm of his wife. Of course I lis- tened with all my ears to the conversation between the two leading English scientists. This event left a lasting and deep impression and is the bright REMINISCENCES. 229 spot in the otherwise foggy memories of London. Mr. Darwin was ill and nearly blind and allowed Mr. HuxIvEy to make nearly all the conversation. It has been a great pleasure to express my deep gratitude to the teachers and masters who were kind enough to take an interest in me and I am free to say that they laid the foundation for whatever I have achieved. In turn I have 'tried to transmit and impart as much as I could to those who have been my pupils or assistants. I feel very proud of some who have stood in this relation to me. Some of them are, I believe, conceded to rank with the best surgeons now living in this country. ■2oO INDKX. INDEX. PAGE Abdomen 80 Abscess 89 Advice to Young Surgeons 10 American Surgery 64 Ansgsthetics 75 Anatomy i 13 Aneurysm 94 Appendicitis 95 Artery— Bleeding 102 Asepsis and Rest 59 Assistance and Assistants 192 Autoptical vs. Autopsical 64 Bile Function , 32 Bladder ; 139 Bones , 104 Books 194 Breast 113 Burns 115 Cancer and Malignancy 205 Chest 117 Damage Suits 46, 47, 48 Death Following Operation 25, 26, 68-70 Didactic Teaching 17 Dislocation 133 Drainage 87 Drugs 63 Ear 121 Education by the State 63 Education of a Surgeon 9 Enthusiasm 71 INDKX. 231 Erysipelas 123 Expert Testimony 47, 48, 49 Fees 50 Fistula and Sinu^ 93, 111 Foot 158 Fracture ; 126 Gallstone Disease 136 Gangrene 59, 138 General 65 Genital , 1?,9, 146 Goitre 157 Goitre, Intralitlgual 29, 30 Gonorrhoea 148 Hand 15S Head 161 Haemorrhage, Treatment 10;i Hernia 168 Hernia — Radical Operation 170 Inflammation 59, 173 Infusion of Saline Solution 103, 201 Intestinal Suture 210 Ischcemic Atrophy from Tight Bandaging 131 , Joints ". 107 Kidneys. 150 Literature 1 94 Malpractice Suits 49 Moist Dressing 178 Mouth 181 Nil Nocere ." 183 Nose 183 CEsophagus 185 282 INDEX. OfBce Surgery 73 Off With the Cloak 52 On Ways and Means of Building Up Practice 43 Operations 1 92 Pelvis " 197 Penis 146 Physiology 1 96 Poisonous Medicines 62 Preface 5 Prescription Doctors 63 Psychical Element 67, Quacks and Charlatans ■ 55 Rectum 199 Reminiscences 219 Rubber Gloves 67 Science and Surgery '37 Scientific Contributions 21 Septic Fever 124 Shock 200 Skin Flaps. . . .' ■ 114 Skull Fractures and Injuries 1 61 Societies 43, 45 Spine 202 Stomach '. 205 Stone 142 Syphilis 151 Text-Books 15, 16 Therapeutics— [lints .155 Throat and Trachea , 213 Time in Bed After Operations 86 Unsuccessful Surgeons 70 Veins, Varicose 217 Warnings and Cautions 77 Important New Medical Books that will be Ready Soon The Diagnosis and Treatment of the Medical Diseases of Women By H. S. Crossen, M. D., Professor of Gynaecology at the Washington University, St. Ivouis, Mo. 300 Pages— Illustrated— Price, $3.00. The Golden Rules of Pediatrics Containing the Important Points in tlie Diag- nosis and Treatment of Diseases of Cliildren By John Zahorsky, A. M., M. D., Clinical Professor of Diseases of Children at the Washington University, St. Louis, Mo. 250 Pages— Cloth Binding— Price, $2.50. Sexual Hygiene and Its Relation to Health A Scientific Presentation of the Sexual Laws and the Rules for their Proper Enforcement By Joseph ly. Boehm, B. S., M. D., Ph. g!, Professor of Genito-Urinary Diseases St. Louis College of Physicians and Surgeons, St. Louis, Mo. 200 Pages— Cloth Binding— Price, $2.00. THE C. V. MOSBY MEDICAL BOOK CO., Publishers ST. LOUIS, MO. AN IMPORTANT BOOK READY EMERGENCY PRACTICE. Willcox's Emergency Practice and Formulary A Book Designed for Ready Reference in Case of Accident and Injury Edited by T. A. Hopkins, A. M., M. D., St. Louis, Mo. CONTENTS: Fractures and Dislocations, Tracheotomy, Ligation of Arteries, Spasmodic Croup, Hsemorrhages, Sunstroke, Wounds, Alcoholism, Anaesthesia, Hernia, Burns and Scalds, Stomach and CEsophagus, Unconsciousness, Eye Accidents, Asphyxia, Ear, Nose and Throat, Convulsions, CEdema of the Larynx, Normal Saline Solutions, Complications of Labor, Dyspnoea, Abortion, Antidotes to Poisons. 300 Pages — Bound in Limp Leather— Pocket Size. Price, $1.00. THEC. V. MOSBY MEDICAI. BOOK CO., Publishers ST. LOUIS, MO. !''''"!'!i{!li!l lii! ddj'l>j jjjjj