THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY
 
 Essays on 
 Surgical Subjects 
 
 By 
 
 SIR BERKELEY MOYNIHAN 
 
 K. C. M. G., C. B. 
 Leeds, England 
 
 Illustrated 
 
 Philadelphia and London 
 
 W. B. Saunders Company 
 
 1921
 
 Copyright, 1921, by W. B. Saunders Company 
 
 PRINTED IN AMERICA 
 
 PRESS OF 
 
 W. B. SAUNDERS COMPANT 
 PHILADELPHIA
 
 ... . 
 Uteiry 
 
 WO 
 <\ 
 
 To 
 
 DR. W. J. MAYO 
 DR. C. H. MAYO 
 
 AND 
 
 My friends at the Mayo Clinic 
 
 A small acknowledgment of a 
 
 great debt 
 
 624000
 
 PREFACE 
 
 THIS book contains a number of essays that have 
 been published at various times during the last few 
 years. A few alterations have been made, and the sta- 
 tistical figures have been brought up to the end of the 
 year 1920. 
 
 The publication, in a single volume, of addresses, 
 lectures, and essays that have appeared in different 
 journals, and at varying intervals of time, may find its 
 justification in that it presents a consecutive train of 
 thought and experience for final judgment. And I 
 may truthfully plead that the wishes of many friends 
 have led me to collect these scattered articles in the 
 present little book which I offer for their consideration. 
 
 My thanks are due to the Editors of the journals in 
 which the articles originally appeared for their per- 
 mission to republish them here. 
 
 BERKELEY MOYNIHAN. 
 
 33, PARK SQUARE, LEEDS, 
 August, 1921
 
 CONTENTS 
 
 PAGE 
 
 THE MURPHY MEMORIAL ORATION 1 
 
 THE RITUAL OF A SURGICAL OPERATION 45 
 
 THE DIAGNOSIS AND TREATMENT OF CHRONIC GASTRIC ULCER 67 
 
 DISAPPOINTMENTS AFTER GASTRO-ENTEROSTOMY Ill 
 
 INTESTINAL STASIS 131 
 
 ACUTE EMERGENCIES OF ABDOMINAL DISEASE 143 
 
 THE GIFTS OF SURGERY TO MEDICINE 167 
 
 THE SURGERY OF THE CHEST IN RELATION TO RETAINED PRO- 
 JECTILES 197 
 
 THE MOST GENTLE PROFESSION . . . 247
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 THE MURPHY MEMORIAL ORATION* 
 
 "The moral of the whole story is this: that voe should do all that we can to partake 
 of Virtue and Wisdom in this life." Socrates is speaking. 
 
 THIS is a day of remembrance. We have come to- 
 gether to do honour to one of the founders of this College, 
 a great surgeon whose loss we mourn. You have laid 
 upon me the duty and the high privilege of offering in 
 your name and in my own, and if I may for the moment 
 assume a wider responsibility, in the name of all the 
 surgeons of his time, a tribute to the illustrious memory 
 of Dr. J. B. Murphy. 
 
 John Benjamin Murphy was an arresting personality. 
 Even after the briefest intercourse with him there were 
 few people who did not realize that he possessed a curious 
 and subtle power of impressing a sense of his character 
 upon them. His very handsome . face, his tall, spare, 
 almost gaunt figure, his high-pitched and vibrant voice, 
 his burning and quenchless enthusiasm for life in all its 
 manifold activities, his power of complete self-expression, 
 all clamoured for notice, and caught and held the most 
 eager attention. His outlook was grave and serious; he 
 seemed always in earnest. The little quips and sallies, 
 the friendly taunts, the provocations to repartee, the 
 illuminating anecdote, which in the United States dis- 
 
 * The first Murphy memorial oration delivered before the American College of 
 Surgeons, at Montreal, October 11, 1920. 
 1 i
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 tinguish the cordial intimacies of daily life, did not seem 
 to play around him as freely as around other men. Even 
 in a crowded room of busy men, or when a debate was 
 keen he would steal a few moments for a whispered 
 conversation, held aloof, on some topic that for the 
 moment filled his thoughts. Among those who knew him 
 well he was admired and deeply respected, rather than 
 loved. Except to a very few he was not genial or respon- 
 sive in friendship. His intellectual attainments were so 
 considerable, and his position in the judgment of his 
 contemporaries so secure, that jealousy hardly touched 
 him, except perhaps in his earlier years and from a few 
 among his seniors whose supremacy he challenged. Such 
 jealousy is perhaps the tribute paid to youth for successful 
 enterprise in thought or in action by minds which suffer 
 from the atheroma of advancing years. We are reminded 
 of the aphorism of Sir Walter Raleigh 
 
 "For whoso reaps renown above the rest 
 With heaps of hate shall surely be opprest." 
 
 Murphy was beyond question the greatest clinical 
 teacher of his day. No one who listened to him can ever 
 forget the experience. Before his audience arrived he 
 had everything very carefully prepared, diagrams in 
 order, microscopes ready, the patients examined, and all 
 relevant literature at his finger ends. There he stood in 
 the middle of the circle, in the theatre, with his assistants 
 and friends in the first row and the other benches packed 
 to the roof with eager students, or with medical men, 
 who came again and again to learn from him afresh. As he 
 began to speak one felt a strange sense of disappointment, 
 and even of dismay. For while the handsome face and 
 upright figure were things of real beauty, the voice in
 
 THE MURPHY MEMORIAL ORATION 3 
 
 which he began to speak was quite unpleasant. It was 
 harsh, even raucous, high pitched, shrill, apt to wander 
 into other keys. It seemed strange that a man of Irish 
 descent, and of so gracious and commanding a presence, 
 should have a voice so lacking in softness, one which 
 not only did not appeal, but actually displeased and 
 almost repelled every listener. But as he continued 
 speaking the voice gradually ceased to distract, it became 
 smoother, quieter, and more evenly pitched, and all 
 thought of it was now lost in rapt attention to the matter. 
 For things were happening even while one's first emotions 
 were roused. Questions were being asked and answered, 
 often with great rapidity, then would come a pause, in 
 which with marvellous directness and power the lesson 
 to be learnt therefrom was driven home. The rally began 
 again. A poor answer came, or an assistant responsible 
 for the clinical notes had omitted to inquire upon some 
 relevant point; raillery came in torrents, never ill- 
 natured, never rancorous, but with just sufficient sting 
 to leave a memory which would stimulate all future work. 
 The discussion warmed imperceptibly; gradually the co- 
 herent chain of argument lengthened, as link after link, 
 forged under our eyes, newly appeared; slowly there 
 came a sense of excitement; of impending revelation; all 
 inquiry, all disclosure, all arguments, were leading up to 
 something that we now ached to learn. Old observations 
 and ancient truths were taking on a new complexion; 
 relations hitherto unsuspected were here declared and 
 explained. The whole intellectual mechanism underlying 
 a great subject was being shewn both in detail and in all 
 the majesty of many moving parts. Perhaps as we drew 
 near to the end, when the whole story would be laid 
 bare, a question barked at one of his audience would fail
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 to be answered. With voice more clamorous, and almost 
 menacing, with face strained and eager, with figure 
 reaching forward and arm outstretched, he would hurl 
 the question at others. Hearts beat faster, the spiritual 
 anguish could hardly be borne. At last the answer would 
 come, and after a final swift induction or brief summary, 
 when the clinical journey was over, we sank back in 
 happiness and mental repletion to wonder if Stevenson 
 could really have been right when he said, "It is a better 
 thing to travel hopefully than to arrive," for this journey 
 had been happy, though anxious enough, but the haven 
 was a rest of tranquillity, and wonder and content. 
 
 And then Murphy would operate. Now of operators 
 there are many types, and like every other work of art, 
 an operation is the expression of a man's temperment and 
 character. There are still among us "brilliant" operators, 
 from whom I pray to be spared when my hour has come. 
 For them it is the mere quality of effort that counts. 
 Their ideal of operative surgery is something swift and 
 infinitely dexterous, something to dazzle the beholder, 
 and excite his wonder that such things can so be done by 
 human hands. The body of a man is the plastic material 
 in which an artist works, and no art is worthy of such a 
 medium unless it has in it something of a sacrament. 
 Surgery of the "brilliant" kind is a desecration. Such art 
 finds its proper scope in tricks with cards, in juggling with 
 billiard balls, and nimble encounters with bowls of 
 vanishing gold fish. But Murphy was of the true faith. 
 He believed in safe and thorough work rather than in 
 specious and hazardous brilliance. He was infinitely care- 
 ful in preparation, and compared with many was inclined 
 to be slow ; but every step in every operation which I ever 
 saw him do was completed deliberately, accurately, once
 
 THE MURPHY MEMORIAL ORATION 5 
 
 for all. It led inevitably to the next step, without pause, 
 without haste; that step completed, another followed. 
 "In sequent toil all forwards did contend." And so when 
 the end came a review of the operation shewed no false 
 move, no part left incomplete, no chance of disaster; all 
 was honest, safe, simple; it was modest rather than bril- 
 liant. During the whole operation Murphy talked; not 
 wasting time, but expressing and explaining aloud the 
 quiet, gentle, dexterous movements of his hands and the 
 purposeful working of his mind. The operation over, 
 he would draw his stool near to the front row of the 
 benches, cross one leg over another, rest his elbow on his 
 knee and talk, as only he in all the world could talk, of 
 surgery in general, of this case in particular, of his faults, 
 of any experiment made to clear a doubtful issue. In 
 these quiet talks there was none of the earlier passion 
 which had gleamed through him, and which, caught up 
 by his audience, had made them throb and tremble with 
 suspense or joy. In them all his former experience, ah" 
 that he had learnt by contact with men and books, all 
 his native ingenuity of mind, were now bountifully dis- 
 played : the vast resources of the keenest surgical intellect 
 of his day were now disclosed, not with ostentation or 
 with florid pride, but in such a quiet manner as to shew 
 that he rejoiced in the privilege of sharing with others so 
 many fascinating and wonderful things. If in answer to a 
 request a little intellectual gift were made to him, it was 
 welcomed with frank, almost boyish enthusiasm, and with 
 a delight and humility obviously genuine. 
 
 Murphy as a writer and as a speaker was prolific. 
 Whenever he spoke men made haste to hear him. His 
 audience, or so it always seemed to me, were often held 
 back from quick appreciation. He was not like other
 
 6 ESSAYS ON SURGICAL SUBJECTS 
 
 men instantly attractive as an orator. Yet, as he devel- 
 oped his argument, little by little, and step by step, the 
 audience warmed to him, he interested them, he in- 
 trigued them, he dominated them, he fired them; intellec- 
 tually he roused them to breathless interest; emotionally 
 they were at times at the limit of self-control. No one 
 could bear to miss a word, and while Murphy spoke no 
 man left his seat. For his meaning was conveyed in 
 pellucid language and though he might speak with the 
 vehemence of raging conviction his thought was never 
 obscured in a smoke of words. Such an intellectual lode- 
 stone was he that appointments were missed and hunger 
 and thirst and fatigue were forgotten. For while Murphy 
 expounded his gospel everything else seemed to fade in 
 importance, overshadowed by the lessons which were 
 now being learnt so eagerly. 
 
 I often wondered, as I listened, in what degree he 
 resembled Lincoln. The tall, gaunt frame, and the harsh 
 and meagre and strident voice were the same. Murphy 
 must have been one of the handsomest men of his day; 
 Lincoln's features were haggard, plain and homely, but 
 his deep and glowing, sad and tender eyes no man could 
 forget. Murphy had no such command of language as 
 Lincoln, certainly one of the greatest orators who has 
 ever spoken our language. But in effect they must have 
 been alike. For they made everything else seem common- 
 place when they spoke, and they seemed to be delivering 
 a message charged with truth and pregnant with con- 
 fidence and hope. Lord Charnwood in his most excellent 
 work on "Abraham Lincoln" writes of him: "His voice 
 when he first opened his mouth surprised and jarred upon 
 the hearers with a harsh note of curiously high pitch. 
 But it was the sort of oddity that arrests attention, and
 
 THE MURPHY MEMORIAL ORATION 7 
 
 people's attention once caught was apt to be held by the 
 man's transparent earnestness." How exactly was this 
 the case with Murphy also! No one who heard Murphy 
 speak ever doubted his sincerity. One might not agree; 
 one might indeed profoundly and confidently disagree 
 with some statement he made, perhaps as though to 
 provoke a challenge, for there was much in Murphy which 
 justified his patronymic, and which discovered his an- 
 cestry; but there was never a thought that Murphy 
 himself was speaking other than his deep and tried con- 
 viction. He never looked at truth askance or strangely. 
 One who heard Lincoln speak at Peoria wrote: "Beyond 
 and above all skill was the overwhelming conviction 
 imposed upon the audience that the speaker himself was 
 charged with an irresistible and inspiring duty to his 
 fellow men." Such an impression was often felt by 
 audiences while Murphy was addressing them. 
 
 One thing Murphy lacked ; in one respect he grievously 
 failed. If we consider the qualities which go to the mak- 
 ing of the greatest surgeons, a foremost place must always 
 be conceded to the capacity to train great disciples. The 
 teaching, the diligence, the general outlook upon surgery 
 and a finished technical skill can all be drilled into the 
 minds, and imposed upon the methods of an earnest 
 student. But it is the inspiration, the lofty sense of a 
 sacred mission worthy of all the best that is in you, the 
 dedication with humblest and fullest devotion to the 'cause 
 of scientific truth, and of loyal service to mankind, that 
 are awakened with a thrill in great men by great teachers. 
 It is here that Murphy fell short. He trained no one 
 worthy to be his successor; no evangelist who could carry 
 into other clinics or to other countries some of his glow, 
 his fervour, his complete devotion, or the full meaning of
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 his gospel. For this great omission there were perhaps 
 some compensations. There were few clinics in any part 
 of the world in which something taught by Murphy or 
 inspired by him had not crept in and found a home. His 
 name was often on the lips of surgeons in all lands. His 
 views impressed themselves on men's minds. His methods 
 were closely copied. But when Murphy laid his mantle 
 down there was no one ready and worthy to take it up. 
 When we remember how the pupils of Turner, of Edin- 
 burgh, became professors in most of the chairs of anatomy 
 throughout the British Empire, how many men Billroth 
 trained to occupy with great distinction the chairs of 
 surgery in eastern Europe, how Welch is the happy parent 
 of a great school of pathologists trained by him, inspired 
 by him, and looking to him with reverent affection, we 
 cannot refrain from regret that some of the acolytes of 
 Murphy did not grow to the stature of High Priests. 
 
 Year by year Murphy grew in intellectual power and 
 in the dominion he exercised over the minds of men. A 
 problem took on a different aspect if Murphy were 
 engaged in it. He touched the common currency of 
 surgical thought and changed it into gold. For no effort 
 of his was meaningless or sterile and all the powers of his 
 mind and of his frail body were spent ungrudgingly in ah 1 
 his work. His well stocked library, and all new literature 
 were searched for him, and dispatches made for his 
 assimilation. He worked as all great men should work, 
 with a clean desk. His great powers were used for worthy 
 purposes and in due season, nothing was wasted in mere 
 hack work, for all that could be equally well done by 
 others was left for them to do. Yet all his life he over- 
 worked. He had an inner restless spirit which drove 
 him at full speed. He must work, and while at work
 
 THE MURPHY MEMORIAL ORATION 9 
 
 there was only one speed, the highest he could command. 
 "I do not wish to linger after my work is done" he said, 
 and it was exactly what might have been expected from 
 him. 
 
 It is useless to wish that men possessed of his qualities 
 and capacities should use themselves differently. A man 
 must do as he must do. If we think that Murphy by 
 spending himself with less lavish extravagance might 
 have prolonged his life another ten years and so have 
 achieved even greater results, to the benefit of all man- 
 kind, we are pondering over one who was not Murphy, 
 and who could not in those early fruitful years have 
 been so avaricious for work, or have so generously poured 
 forth the new truths of which he was at once both parent 
 and missionary. Our designs for another man's life are 
 but futile exercises of an imagination lacking in full un- 
 derstanding, and adrift from realities. 
 
 Such, then, was Murphy as I knew him. It is easy 
 now to see how great a figure he was in the world of 
 surgery of his day. When all his work is reviewed, when 
 not only its range, but the wonderful sincerity and the 
 permanent and piercing accuracy of so large a part of 
 it are considered; when we remember his unequalled 
 gifts as teacher, his power of lucid exposition and of 
 persuasive, or coercive argument, his devotion for many 
 years at least to experimental research, it is no exaggera- 
 tion, I think, to say of him that he was the greatest surgeon 
 of his time. Great men are fitted to their times and in 
 many respects are a reflex of them. But as their times 
 pass their work is seen in far perspective and may appear 
 to shrink in significance. It may then seem to have lost 
 all its originality, and boldness, and force, and we who 
 stand afar off, untouched by the magnetism of a great
 
 10 ESSAYS ON SURGICAL SUBJECTS 
 
 personality, marvel at its influence in its own day. For 
 there are few indeed who enjoy both celebrity and fame. 
 "Mere talents are dry leaves, tossed up and down by gusts 
 of passion and scattered and swept away; but genius lies 
 on the bosom of Memory." How then will it be with 
 Murphy? Judged by the standard of his contemporaries 
 he was an intellectual giant, but of what stature will he 
 be when judged by the standard of history? May I ask 
 you to bear with me while I pass briefly in review some 
 of the main features of the progress of surgery as science 
 and art and tell the tale of some of the great men who have 
 laboured in it, from earliest days up to the present time, 
 so that at last we may see how Murphy stands and 
 what figure he will make in the Great Procession. 
 
 The earliest remains of man known to exist shew 
 that the art of the surgeon was practised upon him. 
 Wherever skulls of the Neolithic period have been dis- 
 covered the openings made in them by the trepan are seen. 
 Dr. Marcel Badouin, in 1908, found within a tomb dis- 
 covered by accident at Belleville the remains of 120 
 human beings. Eight of the skulls had been trepanned, 
 and the edges of the cut bones were smoothly healed over, 
 showing beyond doubt that the patients survived the 
 operation for periods long enough for this to be fully 
 accomplished. The disc of bone removed is supposed 
 to have been worn as an amulet. The operation of tre- 
 panning during the Neolithic period, was also performed 
 in England, in Northern Africa, the Canary Islands, 
 Mexico, and in Peru. It is performed today by the 
 natives of New Ireland, to the east of New Guinea, by 
 methods and with results apparently similar to those of 
 the Neolithic age. Dr. Redman has presented to the 
 Royal College of Surgeons of England a group of five skulls
 
 THE MURPHY MEMORIAL ORATION 11 
 
 shewing the effects of the operation, the instruments 
 by which it is there performed, and the dressings applied 
 to the wound. And travellers tell us that the operation is 
 still practised in the ancient way, so far as can be judged, 
 by the Quichuas of Peru. Surgery is therefore as old an 
 art as any. 
 
 Hippocrates was the first to give form and spirit to the 
 practice of surgery. His observations even when con- 
 sidered with the fuller knowledge of today often bewilder 
 us by their accuracy, insight, and sagacity. His clinical 
 methods judged by our modern standards were broad- 
 based and structurally sound. He recognized not only 
 the nobility of the art of surgery, and the worthiness of 
 its practitioners, but was well aware of the powerful 
 influence which the craft must exert upon the science of 
 medicine. The divorce of hand from brain which modern 
 custom has worked hard to effect derived neither sanction 
 nor authority from any words of his. As he deals with the 
 outward shewing diseases his clinical method is everywhere 
 the same. He observes, reflects, weighs, and judges, con- 
 siders his former experience of the like or analogous con- 
 ditions; he suggests or discovers a general truth; he lays 
 down principles for action, and he tells how the craftsman 
 shall work. If the power of wide and accurate general- 
 ization be, as I believe it to be, among the supremest 
 accomplishments of the human mind, then Hippocrates 
 may in truth be said to have had few rivals, if indeed he 
 has had any, among all those who in later times, and in all 
 countries, have devoted themselves to the science of 
 medicine. For by his injunctions as to the method of en- 
 quiry into the conditions of a patient suffering from any 
 disease he lays down for the first time the principles upon 
 which inductive research is founded. He is the parent
 
 12 ESSAYS ON SURGICAL SUBJECTS 
 
 not of medicine alone, but of the inductive method as 
 applicable to all branches of natural science. It is a 
 proud claim that the method found its first application 
 in the science of medicine. 
 
 His observations upon cerebral injuries were hardly 
 bettered until our own day, and many of his instructions 
 as to their treatment cannot be neglected even now. He 
 notes the effect of brain injuries upon the limbs of the 
 opposite side. His work on fractures and dislocations has 
 received praise from the greatest of critics. Littre spoke 
 of it as "the grandest surgical monument of antiquity" 
 and considered that the truth of its principles was eternal. 
 A century ago the most eminent of French surgeons, 
 Dupuytren, published a work on "Dislocations." Mal- 
 gaigne, whose familiar name justly carries great weight, 
 judged that, in respect of its discussion of congenital dis- 
 locations, the work of Hippocrates was the richer and more 
 accurate. The discourse of Hippocrates on "Wounds," 
 which I read once again in the early weeks of the War, 
 seems to have, in more relations than one, a bearing upon 
 our bitter experience of those most grievous times. Certain 
 it is that for 1500 years afterward nothing so apt was 
 written, by no one were the essential problems of wound 
 treatment so well understood. The dressings applied 
 to wounds, he tells us, were to be of new materials; water, 
 if not clean and sweet, was to be boiled and strained before 
 use; care of the surgeon's hands and nails was thought 
 most necessary. Oil and wine were the balsam for a 
 bruised or dirty wound; or for one long neglected. The 
 accurate apposition of the wound surfaces and the exclu- 
 sion of air were means to secure rapid healing by "primary 
 intention," which was clearly distinguished from "second 
 intention." He dreaded amputation of a limb, especially
 
 13 
 
 near the trunk: these operations today are in respect of 
 their mortality still among the most lethal of all. As Sir 
 John Tweedy has said, "The directions which Hippocrates 
 gives concerning the arrangements of the operating room, 
 the placing of the patient, the position of the assistants, 
 the disposition of the lighting, the care to be taken of the 
 surgeon's hands, the need of ambidexterity, all indicate a 
 careful and experienced practitioner." Hippocrates may 
 count among his greatest glories that he recognized the 
 essential unity of medicine and surgery, or rather that he 
 did not distinguish between them: that he urged and 
 practised the use of all means for the examination of the 
 patient; that he saw no degradation as did so many later 
 ages in the use of a physician's hands in the service of 
 the individual patient, for whose welfare, as Aristotle said, 
 all medicine exists. And his system, which embodied 
 observation, reflection, judgment, all multiplied to make 
 experience which shall decide right action, stands firm 
 until this day. He knew its difficulties, for he tells us 
 that "experience is difficult, verification fallible, observa- 
 tion long and costly, and occasion fleeting." There is one 
 gap, however, a significant one in view of my later con- 
 tention, in his method. He did not put matters to the 
 proof by way of experiment. The experimental verifica- 
 tion or denial of a suggested truth, or the new adventures 
 in thought and action opened up by this method were not 
 for him. 
 
 After Hippocrates we may take a long stride in point of 
 time to the days of Celsus, who lived in the reign of 
 Augustus Caesar. It is interesting to remember that 
 Celsus, the manuscript of whose work "DeRe Medicina" 
 written about 30 A. D., was discovered in 1443 in the 
 Church of St. Ambrose at Milan by Thomas of Sezanne,
 
 1U ESSAYS ON SURGICAL SUBJECTS 
 
 afterwards Pope Nicolas V, was almost certainly not a 
 physician. He was a noble of the family of Cornelii, who 
 wrote works on medicine, agriculture, philosophy, law, 
 and the art of war, in the spirit of an interested amateur. 
 The deep prejudice of the patricians against the adoption, 
 by one of their class, of medicine as a profession was un- 
 conquerable. And the internal evidence in all his writings 
 is opposed to the view that he could have practised as a 
 physician; he mocks at the value of medicine, and esteems 
 the empirical methods of folk medicine as of equal interest 
 and value to the academic methods of his time. He tells 
 us that the true art of medicine lies in the correlation of 
 theory and practice, the one guiding and controlling the 
 other; speculation should guide thought but not deter- 
 mine practice. References to surgical matters are found 
 in all the books, but Books VII and VIII are devoted 
 exclusively to the consideration of surgical matters. The 
 great feature of these is that they record all the changes 
 which had occurred in our art from the time of Hippocrates 
 and especially informs us of the great attainments of the 
 Alexandrian school in anatomy and surgery. He de- 
 scribes wound treatment in detail; arrest of haemorrhage 
 in a wound may be effected by packing and pressure, or by 
 the ligature, which finds its first mention in his work. 
 Sutures are to be used to secure apposition of wound sur- 
 faces and edges, and, as a dressing, linen bandages are to 
 be soaked in wine, water or vinegar. He gives in sufficient 
 detail a description of operations for the radical cure of 
 inguinal and umbilical hernia; and for the first time he 
 refers to the removal of the testis as allowing a firmer and 
 more secure closure of the inguinal canal. He mentions 
 translucency as a test for hydrocele, and describes the 
 tapping of dropsies. He quotes a large number of surgical
 
 THE MURPHY MEMORIAL ORATION 15 
 
 authors, but among them all only Hippocrates is known 
 to us. 
 
 It is evident that by the time of Celsus the boundaries 
 of surgery had been sensibly enlarged, that old procedures 
 had been bettered, as in amputations, and that many new 
 ones had been devised. But progress had been along 
 the old lines, and was achieved by the old methods. He 
 recorded the multiplication and the magnification of old 
 experiences rather than the revelation of new discoveries. 
 He it was who gave us the fulfillment of the promise of the 
 Hippocratic methods. 
 
 But great as were these methods, and considerable as 
 was the success attending their application, there had 
 been a slumber of the intellectual and philosophical 
 aspects of medicine. Hippocrates had united in his 
 own person many divergent and opposing tendencies; 
 after his death there was an acceptance of his teaching by 
 various sects, each adopting a part only, and dogmatism 
 with its cramping tendencies crept in and the spirit of 
 investigation died away. There was need now of a 
 philosopher with new vision, and the need was supplied 
 by Galen. Of Galen's life and character we know much, 
 for he was vain and ambitious, garrulous and verbose. 
 He was trained and deeply versed in ah 1 the current 
 philosophies. A dream of his father, Nikon, interpreted 
 as a vision from the God of Medicine, decided his choice of 
 a profession. After the death of his father he wandered 
 for nine years, studying in Corinth, Smyrna, and especially 
 Alexandria, which then attracted commerce and patients 
 from all parts of the world. His opportunities were great 
 and his use of them unwearying. He wrote works on 
 anatomical and physiological matters, and attained 
 even in these early years of his a reputation for wisdom and
 
 16 ESSAYS ON SURGICAL SUBJECTS 
 
 sagacity. For four years he lived in Rome. His learning, 
 his industry, his friendship with the great and the noble, 
 brought him high repute. But the envy of his colleagues, 
 which he did much to provoke, was his downfall and he 
 fled in fear of his life, to return on the invitation of Marcus 
 Aurelius some twelve years later. But Galen's chief 
 claim to honour, an imperishable one, is that he was the 
 first of physicians to bring experiment to the aid of 
 medicine. As Hippocrates was the parent of inductive 
 method, so was Galen of the deductive. He was the first 
 experimental physiologist. It was he who first discovered 
 and described the cranial nerves, and the sympathetic 
 nervous system; he divided the spinal cord and produced 
 paraplegia; he severed the recurrent laryngeal nerve, and 
 produced the hoarseness and aphonia, which are the 
 constant results of this injury. He discovered the func- 
 tion of a muscle by studying the loss of power which fol- 
 lowed its division. He demonstrated the flow of urine 
 from the kidney to the bladder along the ureters, by a 
 series of experiments than which nothing today could be 
 more conclusive. And he trembled at the very edge of a 
 great discovery when he wrote: "If you would kill an 
 animal by cutting through a number of its large arteries 
 you will find the veins becoming empty along with the 
 arteries; now this could never occur if there were not 
 anastomoses between them." Unhappily experiment 
 alone did not content him, nor experiment in close alliance 
 with clinical observation. His knowledge of anatomy, 
 unsurpassed by any of his time, did not keep him aloof 
 from the wildest speculations in natural philosophy. It is 
 interesting to learn from him that the art of dissection was 
 mainly, if not wholly, confined to certain families, among 
 whom tradition and instruction give rise to a caste of
 
 THE MURPHY MEMORIAL ORATION 17 
 
 dissectors. The members of a family were, from their 
 childhood, exercised by their parents in dissecting, just as 
 familiarly as in writing and reading, so that "there was no 
 more fear of their forgetting their anatomy than of for- 
 getting their alphabet." 
 
 Galen's dissections were confined to the bodies of 
 animals, and the facts so discovered were applied by anal- 
 ogy only to the bodies of men. If a physiological hy- 
 pothesis charmed him, his anatomical observations had to 
 give way to it. His mind ran riot in speculation, often fan- 
 tastic and far-fetched, but occasionally shewing a gleam 
 of real insight, as, for example, in his belief that there 
 was a close primary correspondence between the sexual 
 organs of the male and female. But the evils were 
 great and lasting. It was his rash conceits rather than 
 the facts of his experiments, or his sound anatomical 
 knowledge, and broad scientific purpose which were 
 remembered, and indeed almost sanctified, by all men 
 for a period of over 1500 years. Though he was the first 
 of experimenters he asserted that speculation should lead 
 experience and he exalted a debased metaphysics to a 
 height exceeding that of strict and sober observation. 
 In the times of intellectual stagnation in the Dark Ages 
 the writings of Galen had an enequalled authority; and 
 it was only by a notable independence that Abdollatif 
 dared to assert that anatomy was not to be learnt from 
 books and that even Galen's observations were less 
 to be trusted than the evidences of one's own senses. The 
 result was the sterility and the abasement of medicine 
 until the experimental methods were revived by his direct 
 intellectual descendant, William Harvey. 
 
 In a rather different sense, and in a different scene, the 
 great traditions of medicine were handed on by Avicenna,
 
 18 ESSAYS ON SURGICAL SUBJECTS 
 
 who was born in Bokhara about 980 A. D. It was through 
 him that the works of Hippocrates and Galen became 
 widely known through the East, and finally filtered back 
 to Europe through the Arabs and Moors at a time when 
 learning and culture had almost vanished. The Arabian 
 mind was essentially concerned with compiling knowledge 
 from all sources rather than in initiating enquiry; and a 
 great and useful work, in this direction, was carried out 
 by them during the brightest days of the Saracen Empire- 
 The modern world indeed owes much to their careful 
 preservation of knowledge and their multiplication of 
 copies of standard medical works, before the era of print- 
 ing; even though the science and art of medicine in itself 
 did not, through their efforts, advance one step. In 
 Avicenna we find a mind as keen as that of his great 
 predecessors, viewing the human body and its ailments 
 in his own way, although numerous points of resemblance 
 to the works of Galen and Hippocrates are everywhere 
 evident. He was not an experimenter so much as a 
 philosopher and the power of his mind over so many later 
 centuries is probably to be attributed to his masterly grasp 
 of all sciences as well as of medicine and surgery. In the 
 art of surgery he can hardly have attained the skill of the 
 great founder, as far as can be judged by the records in the 
 Canon. We do not find all those evidences of mastership 
 in technique which shine so strongly through the writings 
 of Hippocrates. As is characteristic of the Eastern today 
 the knowledge which he possessed and, to judge by the 
 records of his successes, utilized with great practical 
 effect, was of a different order, both intuitive and logical, 
 but intuitive before logical. His skill in dealing with 
 fundamental mathematical problems is hardly surpassed 
 at the present day, and in this respect he has been almost
 
 THE MURPHY MEMORIAL ORATION 19 
 
 the only instance of a great mind applying mathematical 
 concepts to medicine and surgery, up till the present era. 
 
 Of other writers before the sixteenth century, it is not 
 unfair to say that they all, or almost all, were merely 
 recorders, encyclopaedists it may be, but devoid of any 
 spark of new thought or of wise generalization. They 
 preserved with reverence the old tradition and the ancient 
 knowledge, they discussed every device, and, at intermin- 
 able length, the meanings of the old scriptures; they 
 tortured new meanings out of old phrases, they were 
 diligent in dressing old words new, and their scholarship 
 was judged by their ingenuity, or infinite prolixity, in so 
 doing. 
 
 The anatomists of the Middle Ages prepared the way 
 for new enlightenment. The oldest treatise on anatomy 
 comes from Egypt. The papyrus dates probably from 
 the reign of Thutmosis I, that is, from before the crossing 
 of the Red Sea by the Israelites. It shews the heart with 
 vessels proceeding from it, the liver, spleen, kidneys, ure- 
 ters, and bladder. The first of comparative anatomists 
 was Aristotle. The expedition of his pupil Alexander 
 into Asia, which he accompanied, gave him unprecedented 
 opportunities for the study of many animals; the result 
 of his work is contained in several books. The first 
 dissections of the human body were made by Erasistratus 
 and Herophilus, of Alexandria. Under the Ptolemies in 
 Egypt were garnered all the fading philosophies and sci- 
 ences which amid the dissensions and distractions of life 
 in Greece, could no longer flourish there. Alexandria 
 then became the guardian and the host of all the sciences 
 and the literatures of the world. It was here, as we have 
 seen, that Galen learnt much of his anatomy. 
 
 After the darkness of succeeding centuries the first
 
 20 ESSAYS ON SURGICAL SUBJECTS 
 
 gleam of dawn was seen in the University of Bologna. 
 For over 100 years it had been renowned as a centre of 
 scholastic knowledge, of literature and of law. Mondinus, 
 the father of anatomy as he is always acclaimed, lectured 
 there between 1315 and 1325, and publicly demonstrated 
 the structures of the body as disclosed by dissection. His 
 descriptions are remarkable alike for their extent and their 
 accuracy. The claim has been made for him that he went 
 near to the discovery of the circulation of the blood, for 
 he says that the heart drives or transmits the blood to the 
 lungs. Two centuries later (1514-1564) was born the 
 greatest of all anatomists, Andreas Vesalius, a native of 
 Brussels, a student at Lou vain. The difficulties of per- 
 forming dissections were so great in France that he went 
 to Italy for freer and larger opportunities. "My study of 
 anatomy," he says, "would never have succeeded had I, 
 when working at medicine in Paris, been willing that the 
 viscera should be merely shewn to me and to my fellow 
 students at one or another public dissection, by wholly 
 unskilled barbers, and that in the most superficial way. 
 I had to put my own hand to the business." When 
 twenty-one years of age he was asked to lecture at the 
 University of Padua. His original additions to the 
 science of anatomy were numerous and of the highest 
 importance. He swept away much of the old ' 'analogical' ' 
 anatomy, the surmises and the errors, hoary with age, and 
 sanctified by their free acceptance by a multitude of 
 authors in the centuries after Galen formulated them. 
 His work on anatomy is adorned with illustrations which 
 for beauty of design and accuracy of execution have never 
 been surpassed, indeed, I think not equalled, since they 
 were published. It is said that the figures were drawn by 
 Titian. Cuvier remarks that if this be not true they
 
 THE MURPHY MEMORIAL ORATION 21 
 
 must at least be the work of one of his most distinguished 
 pupils. But Vesalius did something more than all this. 
 He was the first imitator of Galen in experimental work, 
 and though he did little enough, it was sufficient to show 
 that the method was not utterly forgotten. He was the 
 forerunner of those distinguished Italian anatomists who 
 may share with him the credit for the creation of the 
 science of anatomy, of Eustachius, of Fallopius, who in his 
 short life labored to great ends, and of Fabricius, his 
 successor in the chair of anatomy and surgery of Padua, 
 among whose pupils was William Harvey. The presence 
 of folds in the interior of some veins had been noted by 
 Sylvius and Vesalius and others, and those of the vena 
 azygos were particularly described by Canani in 1547, 
 but it was Fabricius who recognized the existence of 
 valves throughout the venous system and who observed 
 that they were all turned towards the heart. 
 
 Harvey had been attracted by the fame of Fabricius to 
 Padua, at a time when Galileo was teaching and was en- 
 gaging in those methodical researches whose influences 
 have lasted to our own day. Harvey said of himself that 
 he felt it in some sort criminal to call in question doctrines 
 that had descended through a long succession of ages and 
 carried the authority of ancients, but he "appealed unto 
 Nature that bowed to no antiquity, and was of still higher 
 authority than the ancients." It was at the instigation of 
 Fabricius that Harvey undertook by experiment to dis- 
 cover the function of the valves in the venous system, and 
 in the year of Shakespeare's death those experiments whose 
 end was to bring about the greatest discovery in the history 
 of medicine were begun. The discovery had almost been 
 made by half a dozen of his predecessors who appeared to 
 have stood upon its very brink. As Cuvier says, we are
 
 22 ESSAYS ON SURGICAL SUBJECTS 
 
 often on the edge of discovery without suspecting it. 
 There can be little doubt that the pulmonary circulation 
 had been recognized by the unhappy Servetus, who, with 
 his works, was burned as a heretic at Geneva in 1553 by 
 Calvin. 
 
 In 1559, a pupil of Vesalius at Padua, Realdus Colum- 
 bus, may be said to have suggested the existence of this 
 circulation by inductive reasoning, but to ingenious 
 speculation the minds of men were hardened. It was 
 open demonstration and proof that were needed to press 
 home an opinion so contrary to all accepted teaching. 
 
 A discovery is rarely, if ever, a sudden achievement, 
 nor is it the work of one man ; a long series of observations 
 each in turn received in doubt, and discussed in hostility, 
 are familiarized by tune, and lead at last to the gradual 
 disclosure of the truth. Harvey's discovery was finally 
 due to his application of the experimental method of 
 Archimedes and Galen to a problem of which many of 
 the factors were already known ; or, as he himself tells us, 
 the circulation of the blood was held to be completely 
 demonstrated by experiment, observation, and ocular 
 inspection against all force and array of argument. He 
 writes: "When I first gave my mind to vivisections, as a 
 means of discovering the motions and uses of the heart 
 and sought to discover these from actual inspection and 
 not from the writings of others, I found the task so truly 
 arduous, so full of difficulties, that I was almost tempted 
 to think with Fracastorius, that the motion of the heart 
 was only to be comprehended by God. ... At length 
 and by using greater and daily diligence, having frequent 
 recourse to vivisections, employing a variety of animals for 
 the purpose, and collecting numerous observations, I 
 thought that I had attained to the truth."
 
 THE MURPHY MEMORIAL ORATION 23 
 
 The reception of this discovery was generous at home ; 
 tardy and reluctant, or openly hostile abroad. But it 
 was everywhere eagerly and hotly discussed. Harvey 
 says: "But scarce an hour has passed since the birthday 
 of the circulation of the blood that I have not heard some- 
 thing for good and for evil said of this my discovery. 
 Some abuse it as a feeble infant, and yet unworthy to 
 have seen the light; others again think the bantling de- 
 serves to be cherished and cared for. These oppose it 
 with much ado, those patronize it with abundant com- 
 mendation." 
 
 Biolan, distinguished as an anatomist, and professor at 
 the College de France, denied and derided it. What 
 Harvey felt of the opposition may be learnt from his 
 reply to a friend who urged upon him the publication of 
 his later work, De Generatione Animalium: "And would 
 you advise me to quit the tranquillity of this haven, 
 wherein I now calmly spend my days and again commit 
 myself to the unfaithful ocean? You are not ignorant 
 how great troubles my lucubrations, formerly pubh'shed, 
 have raised. Better it is certainly, at some time, to en- 
 deavour to grow wise at home in private than by the hasty 
 divulgation of such things, to the knowledge whereof you 
 have attained with vast labour, to stir up tempests that 
 may deprive you of your leisure and quiet for the future." 
 Nevertheless, compensations and rewards came to him in 
 full measure, and he had the satisfaction of living to 
 see the general acceptance of his discoveries. This dis- 
 covery, as Whewell said, implied the usual conditions, 
 distinct general notions, careful observation of many 
 facts, and the mental act of bringing together these 
 elements of truth. Boyle wrote: "I remember that when 
 I asked our famous Harvey what were the things that
 
 24 ESSAYS ON SURGICAL SUBJECTS 
 
 induced him to think of a circulation of the blood, he 
 answered me that when he took notice that the valves in 
 the veins of so many parts of the body were so placed that 
 they gave a free passage to the blood toward the heart, 
 but opposed the passage of the venal blood the contrary 
 way, he was incited to imagine that so provident a cause 
 as Nature had not placed so many valves without design ; 
 and no design seemed more probable than that the blood 
 should be sent through the arteries and return through 
 the veins whose valves did not oppose its course that way. 
 That supposition his experiments confirmed." 
 
 But the experimental methods of Galen, revived by 
 Gilbert, physician to Queeen Elizabeth and the father of 
 modern experimental science, and practised with such 
 supreme effect by Harvey, was to find as yet no place in 
 scientific surgery. That art it is true was practised with 
 wider scope, with confidence bred of generations of 
 experience, and with a risk that was perhaps steadily, 
 though almost negligibly, diminishing. Safety was rather 
 dependent upon the individual capacity of the surgeon 
 than a quality common to the work of all. Richard 
 Wiseman, who was born three years after the publication 
 of Harvey's discovery, is generally granted the proud 
 title of the Father of English surgery. He was a man 
 "given to the observation of Nature" and became Sergeant 
 Surgeon to Charles II and to James II (who when Prince 
 of Wales and Duke of York were withdrawn under a 
 hedge during the battle of Edgehill, October 23, 1642, when 
 Harvey distracted their thoughts by reading to them), 
 and among his contributions to the craft of surgery may 
 be mentioned his operations for hernia, and his advocacy 
 of primary amputation in cases of injury, by gunshot or 
 otherwise, of the limbs.
 
 THE MURPHY MEMORIAL ORATION 25 
 
 Ambrose Pare was to French surgery what Wiseman 
 was to British. The life of Pare is one of the greatest 
 romances in the history of our profession; it tells the 
 story of the progress of the son of a joiner who was 
 groom, gardener, barber's apprentice, until he became 
 at last the surgeon to four kings of France. It was he 
 who was concealed, locked up in a room of the Louvre, 
 and spared from death by special order of Charles IX 
 at the Massacre of the Huguenots on the day of St. 
 Bartholomew. For the King said that it was not reason- 
 able that a man who was worth a whole world of men 
 should be murdered. He is the outstanding medical 
 figure in the Renaissance. He was untaught and there- 
 fore in youth at least free from the trammels of ancient 
 lore. Early in life he said : "I make no claim to have read 
 Galen either in Greek or in Latin; for it did not please 
 God to be so gracious to my youth that it should be in- 
 structed either in the one tongue or in the other." At 
 last when he read Hippocrates and Galen he surpassed 
 them both in the number and variety of the conditions he 
 had been called upon to treat; and he was therefore 
 the better fitted to approach their teaching in the spirit of 
 an informed and practised critic. "We must not be 
 drugged by the work of the ancients as if they had known 
 all things or spoken ah 1 ," he writes. Yet in later years 
 he studied diligently, for he was said by Thomas Johnson, 
 who translated and edited his works, to be "a man very 
 well versed in the writings of the ancient and modern 
 physicians and surgeons." He was one of the greatest 
 original minds our art has known, fearless, independent, 
 alert and inventive, and not without a good conceit. 
 "There be few men of this profession," he writes, "which 
 can bring so much authority to their writings either with
 
 26 ESSAYS ON SURGICAL SUBJECTS 
 
 reason or experience as I can," and again, "I have so 
 certainly touched the mark whereat I aimed that antiq- 
 uity may seem to have nothing wherein it may exceed us 
 beside the glory of invention, nor posterity anything left 
 but a certain small hope to add some things as it is easy 
 to add to former inventions." He won for surgery and 
 for those who practised the craft in France a place they 
 had never before attained. 
 
 Surgery was still lacking its firm foundation in patho- 
 logical anatomy. This was to be built by Morgagni and 
 John Hunter and by many others taught and inspired by 
 them. The tireless industry, unwearying care, and pro- 
 found sagacity of John Hunter gave to an art that was 
 largely empirical a warrant based upon a sound knowledge 
 of morbid processes in all tissues. He was observer, 
 investigator, collector, in each capacity without a rival. 
 He was unceasing in his search for truth by way of ex- 
 periment. "Don't think, try the experiment," he urged 
 his pupil Jenner. In his own person he did both su- 
 premely well. His disregard of the written word was 
 deplorable no doubt, but refreshing after so much barren 
 speculation among his forerunners. "I am not a reader 
 of books," he said; and again, "I believe nothing I have 
 not seen and observed myself." His rebuff to one who 
 accused him of ignorance of the classics is famous: "Jesse 
 Foot accuses me of not understanding the dead languages, 
 but I could teach him that on the dead body which he 
 never knew in any language, dead or living." Often he 
 recounts the details of an experiment, but leaves us to draw 
 the conclusion. He changed the whole spirit of practice 
 and placed knowledge on the throne of authority. The 
 day was gone forever when a pure and dangerous em- 
 piricism could be practised ; surgery became a science and
 
 THE MURPHY MEMORIAL ORATION 27 
 
 its craft a rational procedure. The museum which he 
 founded and which still bears his name in the Royal College 
 of Surgeons of England is unsurpassed in all the world, 
 and his own specimens are still to be seen to bear witness 
 to his incomparable services to pathological anatomy. 
 For Morgagni no praise can be too high. His letters may 
 be read today with delight; though his knowledge of 
 disease is, in the modern view, often steeped in mediaeval- 
 ism, his long array of facts and of relevant instances, his 
 description of morbid parts, his accurate and searching 
 generalizations are among the greatest contributions to 
 medical literature in all the ages. 
 
 Such was the progress of surgery up to the early years 
 of the nineteenth century. The discovery of the anaes- 
 thetic properties of ether and chloroform completely 
 changed the possibilities of the range of application of 
 surgery to morbid conditions and enlarged also the scope 
 of experimental work upon animals. But in every direc- 
 tion the surgeon's work was hampered and frustrated by 
 the occurrence of infection and all its dire consequences, 
 in the majority of the wounds inflicted. It was for Lister 
 that the world was waiting and his coming changed every- 
 thing. For, as Carlyle said, "The great man was always as 
 lightning out of Heaven : the rest of men waited for him 
 like fuel, and then they too would flame." 
 
 Lister, as every one knows, introduced the antiseptic 
 system into surgery. Before his time the wounds inflicted 
 by the surgeon, or those received in civil life as in cases of 
 compound fracture, became septic almost as a matter of 
 course. The decomposition of the wound discharges was 
 formerly held to be due to contact with the oxygen of the 
 air. Lister recognized that the investigation of many 
 observers, ending with Pasteur, which shewed that fer-
 
 28 ESSAYS ON SURGICAL SUBJECTS 
 
 mentative and putrefactive processes depended upon 
 minute organisms, were applicable in surgical work also. 
 In the year 1836, a French observer, G. Latour, had 
 pointed out that the tiny particles of \vhich yeast was 
 composed were capable of multiplication, that they were 
 in fact alive, and that it was by their propagation that the 
 change known as fermentation, the change of sugar into 
 alcohol, was produced. Both Latour and T. Schwann 
 shewed that this process could be suppressed by the 
 application of heat to the yeast. Schwann, especially, 
 called attention to the fact that the putrefaction of 
 organic substances was due to these minute living bodies, 
 and that putrefaction and fermentation were essentially 
 one. The weighty authority of Liebig was opposed to this 
 view, and Helmholtz, after a time of wavering, finally 
 ranged himself against Schwann. It was in 1856 that 
 Pasteur began the series of experiments which demon- 
 strated finally that micro-organisms were the cause of 
 fermentation and of putrefaction, and that for each form 
 of fermentation studied by him yeast fermentation, 
 lactic acid fermentation, butyric acid fermentation there 
 was one specific cause, and only one. 
 
 Lister had long been working on the problem of in- 
 flammation and of the decomposition of wound discharges. 
 When, therefore, early in 1865 he read of the work of 
 Pasteur his mind was prepared to receive the new evidence, 
 and to put it to the proof in the treatment of surgical 
 cases. It is impossible for us now to realize the horrors 
 and the mortality attached to surgical work at the period 
 when Pasteur's papers were written. In almost every 
 case the discharge from a wound underwent putrefaction; 
 inflammation of varying degrees of severity attacked the 
 wounds, pus poured from their surfaces, and hospital
 
 THE MURPHY MEMORIAL ORATION 29 
 
 gangrene, erysipelas, and pyaemia, the most desperate 
 form of blood poisoning, occurred with terrible frequency. 
 The clean healing of a wound by "first intention" rarely 
 occurred. A surgeon was more than content, he was 
 eager and gratified, to see a thick creamy discharge of 
 "laudable pus" from the surfaces of a wound. Very 
 few operations were performed, and then, as a general rule, 
 only in cases where death or extreme disability was other- 
 wise certain. Limbs were amputated when smashed, or 
 diseased as to be worthless and dangerous; the mortality 
 from amputations varied from 40 to 50 per cent. In 
 Lister's hands, up to the year 1865, in 15 cases of excision 
 of the wrist-joint by his own method, 6 patients suffered 
 from hospital gangrene and 1 died from pyaemia. Volk- 
 mann, one of the earliest of Lister's disciples, had results 
 so ghastly that he decided to close his hospital altogether 
 for some months. Lister's own account of his wards at 
 Glasgow is disturbing and distressing even today. The 
 most vigorous and robust patients were swept away after 
 the most trifling injuries or operations, and septic diseases 
 were so frequent and so deadly that the very name of 
 hospital was dreaded by every sufferer. John Bell, a 
 great surgeon, spoke of the hospital as a "house of death." 
 In the paper which Lister had read, Pasteur asserted 
 that "the most far reaching of my researches is simple 
 enough, it is that putrefaction is produced by living 
 ferments." He asserted that the oxygen of the air was 
 not the cause of putrefaction, as everyone hitherto had 
 supposed ; that indeed some of the causes of decomposition 
 could thrive only in the absence of oxygen. This ob- 
 servation, which distinguishes "aerobic" from "anaerobic" 
 organisms, is of the first importance. Lister at once 
 realized the significance of this work in connection with the
 
 30 ESSAYS ON SURGICAL SUBJECTS 
 
 changes occurring in wound discharges and on wound 
 surfaces. In 1867 he wrote: "When it had been shewn 
 by the researches of Pasteur that the septic property of 
 the atmosphere depended not on the oxygen or any 
 gaseous constituent, but on minute organisms suspended 
 in it, which owed their energy to their vitality, it oc- 
 curred to me that decomposition in the injured part 
 might be avoided, without excluding the air, by applying 
 as a dressing some material capable of destroying the life 
 of the floating particles." He proceeded to make trial 
 of the hypothesis in his own work. At this time he had 
 heard also of the experiments made at Carlisle with the 
 disinfection and deodorization of sewage by German 
 creosote, a crude form of carbolic acid. The administra- 
 tion of a very small proportion of this substance not only 
 prevented all odour from the lands irrigated, but destroyed 
 the entozoa which usually infest cattle fed upon such 
 pastures. This was the preparation he decided, after 
 trying chloride of zinc and the sulphites, to rely upon in 
 his early trials. 
 
 Among surgical cases then, as now, the sharpest 
 distinction was drawn between simple and compound 
 fractures; between fractures, that is, where the soft parts 
 are almost unhurt and the skin unwounded, and frac- 
 tures in which a wound through the skin and soft tissues 
 reaches the broken ends of bone. In simple fractures, life 
 was rarely or never in jeopardy; in compound fractures, 
 putrefaction of wound discharges occurred, septic proc- 
 esses became rampant and the mortality was high. "The 
 frequency of disastrous consequences in compound frac- 
 tures, contrasted with the complete immunity from danger 
 to life or limb in simple fracture, is one of the most 
 striking as well as melancholy facts in surgical practice."
 
 THE MURPHY MEMORIAL ORATION 31 
 
 These were the opening words of Lister's first paper on the 
 "new methods" in the Lancet in 1867. The first trial 
 of this method proved disastrous owing to improper 
 management, but the second attempt, on August 12, 
 1865, proved perfectly satisfactory, and w r as followed by 
 others which more than realized Lister's most sanguine 
 expectations. Compound fractures healed and united as 
 easily and quickly, and almost as safely, as simple frac- 
 tures. The method proved by so stern a trial was soon 
 applied to cases of chronic abscess, and by degree to opera- 
 tion wounds. In one of his earlier papers Lister wrote: 
 "Admitting then the truth of the germ theory and proceed- 
 ing in accordance with it, we must when dealing with any 
 case destroy, in the first instance, once for all any septic 
 organisms which may exist within the parts concerned; 
 and after this is done, our efforts must be directed to the 
 prevention of the entrance of others into it." This state- 
 ment shews that Lister laid down the two essential 
 principles of antiseptic system, the prophylactic and the 
 therapeutic. 
 
 Lister's work, it is evident, was the result of research 
 carried out both by the inductive and by the deductive 
 method, and tested and confirmed by many experiments. 
 He combined in full measure the wide, patient, penetrating 
 inquiry, the comprehensive generalization, and the sound 
 wisdom of the method of Hippocrates, with the demand 
 for experimental illumination or proof afforded by the 
 method of Galen, of Bacon, and of Harvey. He combined 
 in his own work the best of all the schools, and it was no 
 accident that the greatest of all discoveries relating to the 
 science and the art of surgery was made by him. 
 
 If a man's services to humanity are the standard by 
 which we measure his value, then Lister may be counted as
 
 32 ESSAYS ON SURGICAL SUBJECTS 
 
 perhaps the greatest man the world has ever produced. 
 For he has been the means of abolishing, or assuaging, 
 the sufferings of men and women to a degree which is 
 quite incalculable, and, as I said of him years ago, he has 
 been the means of saving more lives than all the wars of 
 all the ages have thrown away. 
 
 As the result of Lister's work the way was cleared for 
 an immense and immediate advance in surgical practice, 
 and for an extension into regions that before had been 
 denied even to the most intrepid surgical adventure. 
 The result is known to all the world. Diseases which were 
 beyond the reach of any are now within the grasp of all 
 surgeons. Operations whose mortality even twenty-five 
 years ago was so heavy as to be almost prohibitive are 
 now performed with a frequency and with a degree of 
 safety which never cease to excite our wonder. But Lis- 
 ter's work did something else; it shewed how research 
 for the future must be conducted if our progress were to 
 be both enterprising and safe. It shewed that clinical 
 research and experiment must forever run together. 
 
 The achievements of clinical research have been 
 gigantic since Lister's day. The safety which he brought 
 into all our work resulted in an advancement, little by 
 little, of the attack upon the diseases of internal organs, 
 and it exercised in consequence a very powerful, germinal 
 influence upon internal medicine. If our knowledge of 
 the disease of the abdominal viscera of thirty years ago 
 is compared with that of today the truth of this statement 
 will appear. In connection with the diseases of the gall- 
 bladder and bile-ducts the work of Courvoisier published 
 in 1890 is a complete record : it is, indeed, one of the most 
 monumental works ever produced in surgical literature. 
 What was known then, in comparison with now? Nothing
 
 THE MURPHY MEMORIAL ORATION 33 
 
 of the early symptoms of gall-stones, of the relation be- 
 tween them and visceral and other infections, nothing 
 of the symptoms due to the impaction of stones in one or 
 other of the ducts; almost nothing of the possibilities of 
 safe relief by surgery. Lister's work has not only been 
 the means of relief to the patient in his agony, but has 
 been the instrument by which our own most prolific en- 
 quiries into the symptomatology, etiology, and, in no in- 
 significant degree, the pathology of this disease has been 
 made. Of gastric ulcer as distinguished from cancer of 
 the stomach our knowledge thirty years ago was trivial 
 compared with what it is today. Much of the teaching 
 of those days is not confirmed by the surgical enquiries 
 of today; and it is now I suppose admitted universally 
 that unless the physician is guided by the principles of 
 diagnosis discovered by the surgeon and the radiographer 
 he will stray wide from the path of truth. So, too, of 
 duodenal ulcer, our present knowledge of which is due 
 entirely to the clinical research made possible by safe 
 surgery. And the list might be greatly extended. Much 
 more remains to be done. We are only on the threshold 
 of our enquiries as to the complementary action of one 
 organ upon another; of the relations, for example, of 
 the pancreas, spleen, and liver to each other; and of all 
 or any of these to parts, or to the whole, of the alimentary 
 canal, and to the organs possessed only of an internal 
 secretion. Clinical research involves and implies the 
 fullest enquiry into the detailed character of all present 
 symptoms; the most searching pursuit after those earliest 
 departures from smooth and normal action which observa- 
 tion can discover, the correlation of all these with the 
 manifest changes observed at all stages in the several 
 organs during operations upon any of them. When all 
 
 3
 
 3U ESSAYS ON SURGICAL SUBJECTS 
 
 this knowledge has slowly and patiently been garnered, 
 then the method of experiment must be used to carry our 
 enquiries still further, and to help us to answer the ques- 
 tion: "How do these things happen?" Clinical research 
 will tell us of the changes in other organs associated with 
 the one to which our main enquiry is directed, but a 
 process of deduction and an enquiry by experiment are 
 necessary before we can disclose the sequence of events 
 which culminate at last in the disease we set out to study. 
 The clinical research, is beyond question, the more arduous. 
 The factors which enter into it are so many, so variable, so 
 impressed by the changing conditions and moods and 
 circumstances of the patient that only the most inde- 
 fatigable patience and the most trained capacity can help 
 to resolve the matter into simple terms, to dissociate 
 what may be an infinitely complex grouping of many 
 facts before we can rearrange them in appropriate sequence 
 of process or of time. We must discover the "usual 
 conditions," obtain our general notions, observe carefully 
 a multitude of facts, arrange them in orderly fashion, 
 employ the mental act which will bring them together 
 as elements in a great truth. When this is done, and only 
 when this is done, can the deductive method of Galen 
 be employed to fullest advantage. Experimental re- 
 search is not so baffling a task. Great ingenuity in the 
 devising of experiments may be found in the supreme 
 masters, Pawlow, Almroth Wright, and a very few others. 
 But each experiment often contains only the one question 
 to which the answer is sought. The answer is "yes" or 
 "no," or is expressed in simple terms, and it is free from 
 those infinite perplexities and changing proportions which 
 distinguish the answer given to any enquiry, even the 
 simplest, in the method of clinical research. When in a
 
 THE MURPHY MEMORIAL ORATION 35 
 
 simple experiment the answer is given, a new problem may 
 arise suggesting a further experiment. Thus a chain of 
 experiments may develop each of which answers not only 
 its own question, but contributes in its own degree to the 
 final answer embracing the entire sequence of experiments. 
 The single experiment may be simple. But in respect of a 
 series, each member of which is dependent upon its 
 predecessor, and provokes its successor, and all of which 
 illuminate or decide some problem suggested by clinical 
 research, nothing has been done in surgery comparable 
 to that which in chemistry has been achieved by Fisher 
 and Abderhalden. 
 
 These brief glimpses at the progress of surgery shew 
 that its epochs may be considered as three in number. 
 
 In the first and longest the writings of Hippocrates 
 and Galen were regarded as an inspired gospel. By them 
 the minds of men were held captive, and their imagination 
 enslaved, and every new adventure in thought or action 
 suppressed or cramped. To seek in them for knowledge 
 was all the effort of every man. What was written in 
 them was truth, what was outside them rank heresy. 
 Where the meaning was not as plain as day the most 
 endless enquiry and discussion ensued. The controversies 
 which then shook the intellectual world to its very founda- 
 tion are seen now to be only laughable, both in their 
 methods and in their quaint decisions. In later ages to 
 challenge the truth or the final revelation of any teaching 
 of Galen's was almost blasphemous, and it required a rare 
 and reckless courage to say, as did Henry of Mondeville, 
 "God did not surely exhaust all his creative power in 
 making Galen." The prophets and seers, who little by 
 little, and with very needful caution, led the world through 
 this black night, death's second self, into the dawn, were
 
 36 ESSAYS ON SURGICAL SUBJECTS 
 
 the anatomist Mondinus, Vesalius, Fabricius, Fallopius, 
 and others. By their work the assertions of the old 
 scriptures could be openly gauged. In gross anatomy a 
 structure stands out for all to see. If Galen's teaching 
 denied the truth disclosed by dissection it was most gently 
 and tentatively refuted, heretical and perilous as such a 
 work might be. And as normal anatomy grew it was 
 joined by morbid anatomy, and at last came Morgagni 
 and Hunter. They established the second great era in 
 which the pathology of the dead was studied with a 
 wealth of care and inexhaustible patience. The gross 
 lesions of morbid anatomy, and even many that were 
 recondite and remote, were examined, described, dis- 
 cussed, and arranged in due order by a mighty succession 
 of able men, whose work today we too lightly neglect. 
 Clinical medicine and surgery were dominated by the 
 knowledge of the morbid processes discovered in this time. 
 Symptoms were correlated with the signs found upon the 
 postmortem table and upon the shelves of museums. 
 Clinical histories were largely devoted to terminal con- 
 ditions, for it was only these that brought a patient to a 
 hospital where he died, and where an autopsy could be 
 made. But patients do not die in hospital from the dis- 
 eases from which they suffer long during life. And in 
 consequence severe limitations were set to our knowledge 
 of disease of all kinds. 
 
 Lister's work made possible the third era which de- 
 pended for its swift and notable advance upon a study of 
 the pathology of the living, upon a study, that is, of 
 morbid processes in their course rather than when their 
 race was fully run. By multiplying observations made 
 during operations we learnt, little by little, how to 
 capture a general truth from a series of individual exam-
 
 THE MURPHY MEMORIAL ORATION 37 
 
 pies. By slow degrees and grudgingly it was admitted 
 that terminal manifestations of disease and the advanced 
 ravages of morbid anatomy did not constitute all medi- 
 cine; that earlier symptoms w^ere to be referred to earlier 
 changes in organs exposed during the course of operations. 
 And these changes and symptoms we now realize are 
 themselves but late; still earlier manifestations of aber- 
 rant action are being sought patiently and with a success 
 that holds increasing hope for future work. 
 
 During all these three periods, through Galen, Vesalius, 
 Harvey, Bacon, Hunter, Lister, there has run a vein of 
 experimental work, testing hypothesis and discovering 
 new truths. Since Lister's day there has been a steadily 
 increasing recognition of the value of such work and of 
 the urgent necessity of continuing it, of enlarging its field 
 so that it may be coterminous with medicine itself. We 
 are, indeed, newly entered upon another stage, the stage 
 of combined research, in which clinical observation, in- 
 ductive and deductive processes of reasoning, and ex- 
 perimental enquiry are linked together. In its progress, 
 so far, the work of a few men stands out as of the utmost 
 significance. Horsley's work upon myxcedema, cretinism, 
 and on the functions of the thyroid gland; Terrier's, 
 Macewen's, and Horsley's researches upon cerebral affec- 
 tions and cerebral localization; Senn's work upon the 
 pancreas and upon the intestines; Kocher's work upon 
 cerebral compression and upon the thyroid gland; Crile's 
 work upon shock and upon blood transfusion ; and Harvey 
 Cushing's work upon diseases of the brain and the pitui- 
 tary gland. Since Lister rid all operations upon man and 
 upon animals of their former terrors, many surgeons have 
 turned to experiment in order to perfect and to illustrate 
 their own work, to test an hypothesis, to search for new
 
 38 ESSAYS ON SURGICAL SUBJECTS 
 
 procedures or to discover an explanation of clinical 
 phenomena whose meaning was difficult to unravel. In 
 recent days few men have displayed so vast a range of 
 clinical interests, so keen a zest for relevant experimental 
 enquiry, so logical a mind, such frank intellectual honesty 
 as Murphy. He may justly be ranked as one of the 
 earliest and one of the greatest exponents of the method of 
 combined research. 
 
 Murphy's first work to attract the attention of all 
 surgeons was that which led him to devise and to perfect 
 the most exquisite surgical implement that has ever been 
 invented, "Murphy's button." Up to the time at which 
 experimental work on the anastomosis of hollow abdominal 
 viscera was begun by Senn, Murphy, and others, the 
 method of securing union was difficult, tedious, and un- 
 safe. I well remember to have seen the operation of 
 "pylorectomy" done in the year 1889. A very niggardly 
 removal of a small "prepyloric" carcinoma was made, and 
 the cut end of the duodenum was united to a part of the 
 divided end of the stomach after the first method of Bill- 
 roth. We counted over two hundred sutures used to 
 effect the junction. Each suture was of silk; for each the 
 needle was separately threaded, the suture passed, tied, 
 and cut; a wearisome total of movements of the surgeon 
 and his assistants, involving a great expenditure of time. 
 No wonder the surgeons searched for simpler methods. 
 Senn's bone plates, the first mechanical apparatus to 
 assist in an anastomosis, were ingenious instruments not 
 very easy to use, requiring a not inconsiderable degree 
 of skill and patience to secure, that the threads holding 
 them were well and truly tied, and calling also for the 
 introduction of a number of additional sutures. The 
 results following the use of these instruments were some-
 
 THE MURPHY MEMORIAL ORATION 39 
 
 times very good and sometimes very bad. While surgeons 
 were struggling with this tiresome and unsatisfactory 
 implement, Murphy introduced his "button." It was 
 the result of a great deal of experimental work done upon 
 dogs, in the early hours of the morning, and in the lean 
 years of his early married life. In this work Mrs. Murphy 
 took her share, giving chloroform to the animals. A few 
 people were privileged to know of the boundless help and 
 inspiration which Mrs. Murphy gave her husband in those 
 hard, but happy days when he was struggling for his place 
 in the world of surgery. His wonderful success was in no 
 small way due to her sympathy, encouragement, and un- 
 faltering belief in him; and to the eager enthusiasm which 
 she shewed in all his work. His fame was her fame also. 
 As I offer to him my tribute of laurel for honour and of 
 rosemary for remembrance, it is an added pride that I can 
 do so in her presence. With the help of Murphy's button 
 operations which had been difficult and perilous at once 
 became so simple that the merest tyro could perform them, 
 and the risk of all operations fell with amazing rapidity. 
 The button was used in every clinic and upon all occa- 
 sions where visceral anastomoses had to be effected ; and 
 the name and the fame of Murphy travelled round the 
 world. But I still think that the great virtue of the 
 button was not in its own direct use, but in the convincing 
 demonstration it gave to us of the essential simplicity 
 of the process of visceral union. By using the button we 
 learned how safely and how rapidly the peritoneal junc- 
 tion took place; there was no need, it was now perfectly 
 evident, for the hundreds of stitches that all surgeons 
 were using. Firm, even approximation for a very few 
 days would lead, the button showed beyond a doubt, to a 
 permanent and secure fusion of the apposed viscera.
 
 40 ESSAYS ON SURGICAL SUBJECTS 
 
 The button itself was occasionally a danger. After the 
 operation of gastro-enterostomy it sometimes remained 
 for many months in the stomach ; when it passed on to the 
 lower intestine it might cause obstruction, or it might 
 ulcerate its way through the intestinal wall. We learned 
 from the use of the button not that the button itself 
 should be used, but all the secrets of the principles of 
 entero-anastomosis. It is not the least exaggeration to 
 say that Murphy revolutionized the methods of visceral 
 anastomosis, and was partly responsible for giving that 
 impulse to abdominal surgery which in later years has 
 carried it so far. 
 
 A characteristic example of his method of approach- 
 ing a surgical subject to which he desired to contribute 
 is shewn in his work on "Ankylosis," which he began 
 in 1901. Up to that time the treatment of stiff joints 
 was unsatisfactory, and in cases of severe ankylosis, 
 whether bony or densely fibrous, was almost hopeless. 
 Murphy says he proposes to begin the study of his subject 
 by some questions: "What are joints? What is the 
 embryology of joint formation? What is the pathological 
 histology of aquired arthoses, of false joints? What is the 
 pathology of hygromata? (acquired endothelial lined sac) 
 Can they be produced artificially? What is ankylosis? 
 What are the pathologic and anatomic changes included 
 in the term? What tissues are involved? From a 
 practical standpoint, into what classes may it be divided? 
 When ankylosis has formed, what are the limitations of 
 surgery for its relief? Can we re-establish a movable, 
 functionating joint with synovial lining? Can we restore 
 motion, and to what degree? In what class of cases can 
 the best results be secured? Can we for the future
 
 THE MURPHY MEMORIAL ORATION M 
 
 promise better than the flexible, fibrous unions that we 
 have secured in the past?" 
 
 He then discusses the development of joints in the 
 embryo, and the method of bursa formation in early and 
 in adult life, shews that hygromata and ganglia are the 
 products of the liquefaction of hypertrophied connec- 
 tive tissue, and indicates that in an artificial development 
 of joints all the facts relative to these processes should be 
 utilized. The formation of "false joints" as a result of 
 non-union in fractures of the long bones led to the 
 recognition of the pathological condition whose counter- 
 part was provoked in the operation of arthroplasty, in 
 which a foreign body was inserted between the end of 
 bones separated at an ankylosed joint, to prevent re- 
 union and to cause the development of a new joint. He 
 then investigates the matter by experiments upon dogs, 
 and proceeds to demonstrate its efficacy upon men 
 afflicted by bony ankylosis of their joints. The whole 
 piece of work is an exemplary instance of the combination 
 of clinical experience and of experimental research leading 
 to the establishment of a new method of treatment in a 
 severe and most disabling condition. 
 
 In 1897, Murphy published his article, "Resection of 
 Arteries and Veins Injured in Continuity. End-to-End 
 Suture; Experimental and Clinical Research," in which 
 for the first time he established the principles, and 
 described one of the methods, of arterial suture and 
 anastomosis. As in other articles, clinical needs indicate 
 the lines of his experimental enquiries; and a widening of 
 the bounds of surgical endeavour and practice is the result. 
 In 1898, he delivered at Denver the Oration on Surgery 
 before the American Medical Association and chose as 
 his subject the "Surgery of the Lungs." Independently
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 of Forlanini he suggested the injection of nitrogen into 
 the pleural cavity in cases of hopeless unilateral disease 
 of the lung. No enthusiastic acceptance greeted the 
 suggestion. Murphy himself extended the method in his 
 later work to cases of incipient tuberculous disease ; and 
 recent experience has fully justified all his claims and has 
 given sanction to his methods. He again combined 
 clinical experience and research by experiment in his 
 work on "Surgery of the Spinal Cord," published in 1907, 
 and his final summary on neurological surgery in Surgery, 
 Gynecology, and Obstetrics, 1907, iv, 385, was the most 
 accurate and concise survey of our knowledge of this sub- 
 ject which had then been published. 
 
 Wherever we turn we find his method to be the same. 
 A wide survey of the subject to be discussed made in- 
 teresting by the personal magic that he was able to throw 
 into it; a disclosure of the gaps in our knowledge; a sug- 
 gestion as to the means by which that knowledge or a 
 want in our technical methods can be made good ; a record 
 of experiment to elucidate or to solve a difficult point; 
 a wealth of clinical observation and a formidable array 
 of arguments, lead to an inevitable conclusion stated in 
 terms that none could fail to comprehend. In every 
 article of his that we read we can see the working of an 
 orderly mind, of a mind most eager for new truths, and 
 expectant of them. For every subject he seems to have a 
 mental scaffolding by which he guides and arranges the 
 truths as they are fashioned and duly laid in place. He 
 had a zeal for classifications which looked complex, but 
 when carefully considered tended to simplicity and to 
 easy and ready remembrance. Of his other surgical 
 work and of his high-minded endeavour to seek for and to 
 secure the purity and advancement of his own profession
 
 THE MURPHY MEMORIAL ORATION 43 
 
 I need say nothing. It is a record of sincere and honest 
 devotion to his duty as he saw it before him. Great 
 deeds are born of great zeal and high resolve ; and he was 
 lacking in neither. All that he did is within the recent 
 memory of his colleagues here. My immediate purpose 
 has been fulfilled if I have sketched, however roughly, 
 the giant figure of the man and the surgeon whose work 
 was done among you and whose fame has spread out into 
 all lands. 
 
 Our calling by common consent, the noblest of any, 
 dignifies all who join its ranks. The honour of the pro- 
 fession is the cumulative honour of all who both in days 
 gone by and in our own time have worthily and honestly 
 laboured in it. In every generation there are a chosen 
 happy few who shed a special lustre upon it by their 
 character, their scientific attainments, or the great glory 
 of their service to their fellow men; for it is, as Ambrose 
 Pare said, "beautiful and the best of all things to work 
 for the relief and cure of suffering." In our generation 
 Murphy was one who by his full devotion, his complete 
 surrender to its ideals, and by his loyal, earnest, and un- 
 ceasing work, added distinction to our profession, which, 
 in return, showered upon him the rewards with which no 
 others can compare, the approbation of his fellow workers 
 and the friendship and trust of the best among his con- 
 temporaries in every country. 
 
 "The mightier man, the mightier is the thing 
 That makes him honoured." 
 
 As we look backward upon the long history of the 
 science and art of medicine we seem to see a great proces- 
 sion of famous and heroic figures, each one standing not 
 only as a witness of his own authentic achievements, but
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 also as a symbol of the traditions, ideals, and aims of 
 the age which he adorns. The procession is sometimes 
 thinly stretched out, or even rudely broken here and there, 
 but in happier ages it is thronged by an eager and exult-. 
 ant crowd. In medicine the whole pageant is as noble 
 and splendid as in any of the sciences or arts, and it 
 reveals the collective and continuous genius of a band of 
 men inspired by the loftiest purpose, and lavish in labour 
 and sacrifice for the welfare of mankind. They have 
 come throughout the ages from every land. They now 
 belong not to one country but to every country, for they 
 are the common possession and the pride of all the world. 
 They have lost their nationality in death. They are 
 men whose deeds will not be forgotten and whose names 
 will live to all generations. Among such men, few in 
 number, supreme in achievement, John Benjamin Mur- 
 phy is worthy to take his place.
 
 THE RITUAL OF A SURGICAL OPERATION* 
 
 EVERY operation in surgery is an experiment in bac- 
 teriology. The success of the experiment in respect of 
 the salvation of the patient, the quality of healing in the 
 wound, the amount of local or constitutional reaction, 
 the discomforts during the days following operation, and 
 the nature and severity of any possible sequels, depend 
 not only on the skill but also upon the care exercised by 
 the surgeon in the ritual of the operation. The "ritualist" 
 must not be a man unduly concerned with fixed forms 
 and ceremonies, with carrying out the rigidly prescribed 
 ordinances of the surgical sect to which he owes allegiance; 
 but a man who, while observing with unfaltering loyalty 
 those practices which experience and experiment have 
 together imposed upon him, refuses to be merely a 
 mimic bound by custom and routine. He must set 
 endeavour in continual motion, and seek always and 
 earnestly for simpler methods and a better way. In the 
 craft of surgery the master word is simplicity. 
 
 The ritual of an operation commences before, some- 
 times long before, the incision is made, and may continue 
 for a long period after the wound is healed. In the transi- 
 tion of a patient from ill health to sound health the opera- 
 tion itself is only one though it may be the most im- 
 portant of all the factors concerned in this fortunate 
 event. 
 
 * Remarks made at the opening of a discussion at the first meeting of the 
 Rritish Association of Surgeons, held at the Royal College of Surgeons, May 14, 
 1920. Reprinted from The British Journal of Surgery, Vol. VIII, No. 29, 1920. 
 
 45
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 In this discussion we are not asked to deal with two 
 essential preliminary propositions, the necessity for the 
 most careful clinical inquiry into all aspects of the patient's 
 history and condition, so that accuracy of diagnosis may 
 be achieved before operation; and the exact relevance of 
 the proposed operation in the particular conditions rec- 
 ognized by this inquiry, or discovered during the course 
 of the operation itself. A great many mistakes are still 
 made in both these matters. It is useless, to say the least, 
 to perform the most perfect technical operation in 
 conditions which do not call for it; and the test of a 
 successful operation is not restricted to the healing of 
 the wound, but to the ultimate effects of the procedure 
 upon the disorder of the patient. 
 
 When conducting our experiment in bacteriology we 
 must recognize that micro-organisms capable of causing 
 the direst disaster may possibly be everywhere in the air, 
 on the hands, instruments, gauze, catgut, etc., which may 
 be introduced into the wound, or upon the surface of the 
 patient's body. The possibility of the patient's own 
 tissues furnishing a septic organism is so remote that 
 we may leave it out of account entirely. It is an excuse 
 to condone rather than a reason to explain the occurrence 
 of infection. 
 
 Our bacteriological experiment may be conducted with 
 one of two intentions: (1) The exclusion of all organisms 
 from the wound; (2) the destruction of all organisms 
 reaching the wound, by a bactericide applied to the wound 
 surfaces. 
 
 It is not accurate to speak of these two methods as 
 those of "aseptic" and "antiseptic" surgery; for to speak 
 strictly there is no "aseptic" surgery. In every operation 
 some antiseptic is used on the surgeon's hands or the
 
 THE RITUAL OF A SURGICAL OPERATION 47 
 
 patient's skin. The terms are accurate enough if they 
 are held to apply only to that part of the operation which 
 begins with the incision of the skin. After this point the 
 use of antiseptics in a "clean" case is rarely necessary, 
 is often undesirable, and is almost always of greater harm 
 than benefit. It is to insult tissues and to doubt them, 
 when it would be better to trust their very considerable 
 powers of self-defence. 
 
 In speaking of the results of an operation a surgeon 
 may be a prejudiced witness as to his own efforts, and a 
 bad judge of his own merit. When we speak, for example, 
 of "healing by first intention," what do we mean? What 
 is our standard? Let us take extreme examples. In the 
 one we mean a wound which heals within a few days, 
 leaving a thin, straight, narrow line of palest pink. 
 Around this line and the stitch-marks everything appears 
 "cold." There is no redness, no swelling, no stiffness or 
 induration, and at the line itself the most accurate 
 apposition of skin edges is seen. There is no discharge 
 from the wound. There has been neither local nor 
 constitutional reaction following the operation. In the 
 other, we mean a wound which is anything but straight; 
 the edges are jagged, they do not meet accurately at 
 every part, they overlap here and there; the line of healing 
 is broad and irregular, raised and red, a sticky discharge 
 oozes from the unapposed surfaces, and a scab may lie 
 where this discharge has dried. The parts around are 
 raised, tender, doughy, or stiff. The stitches seem to 
 sink into the skin. You may see wounds of this kind in 
 some clinics, and hear a complacent comment that the 
 wound has healed by "first intention." Such wounds are 
 the clearest evidences either of a bad technique or of a 
 clumsy operator, or perhaps of both. If we had a Dr.
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 Johnson in our profession, and he were asked his opinion 
 of such wounds, what would he thunder in reply? We 
 know what he said when pressed for his opinion of a young 
 lady's verses: "Why, they are very well for a young 
 miss's verses; that is to say, compared with excellence, 
 nothing; but very well for the person who wrote them." 
 
 In every discussion it is necessary for the protagonists 
 to agree as to definitions and the exact meaning to be 
 attached to words; otherwise polemics are valueless. We 
 must here discriminate between "perfect" and "imperfect" 
 healing, though both may be classed as examples of healing 
 by "first intention." It is, moreover, not only a question 
 of the healing of the superficial, visible wound which is 
 our concern. With the two types of wound healing I 
 have described there are associated not only the varying 
 chances of fife or death but also two types of convales- 
 cence, especially in abdominal cases. In the former the 
 patient suffers hardly at all, indeed, as a rule, not at all, 
 unless there have been great technical difficulties in the 
 operation itself, such as remoteness of the parts concerned 
 in a very stout subject. 
 
 For example may be quoted an operation for chole- 
 lithiasis, in a very fat woman, when the liver lies high, 
 and the gall-bladder is small, bound up in dense adhe- 
 sions, fixed to the duodenum (perhaps with a fistula into 
 it) and the back of the abdomen. The fiver and costal 
 margin may need to be held up, and the abdominal vis- 
 cera to be dragged downwards, before the sclerosed gall- 
 bladder or a dilated common duct containing a stone can 
 be seen. I know nothing in surgery which approaches 
 such cases in difficulty, or which requires such care, gen- 
 tleness, patience, and skill on the part of a surgeon. I 
 sometimes hear the operation for the removal of a Gas-
 
 THE RITUAL OF A SURGICAL OPERATION U9 
 
 serian ganglion or the avulsion of its sensory root spoken 
 of as "difficult." It is work for a novice compared with 
 that in many a gall-bladder case. Apart from cases such 
 as these, which require firm handling, the amount of reac- 
 tion is negligible. More than half the abdominal cases, 
 except for a little flatulence, hardly realize that they 
 have had an operation performed. Flatulence is a trou- 
 blesome complication not only of abdominal, but of other 
 operations also. Its cause is uncertain. My own view is 
 that it chiefly results from the starvation and purgation 
 which are almost universally considered a necessary part 
 of the ritual of deliberate operations. Both are certainly 
 undesirable, and are possibly harmful. Solid food is 
 much like liquid food by the time it gets well on its way 
 in the jejunum. As much fluid as the patient wishes to 
 have should be allowed to within an hour or two of the 
 time arranged for any operation, and as soon as possible 
 afterwards. Operations on the stomach are no exception. 
 An enema generally clears the colon quite as much as is 
 necessary. Aperients increase the number and the viru- 
 lence of the intestinal micro-organisms, and are apt to 
 deprive the patient of large amounts of fluid and to cause 
 exhaustion : effects which are all most undesirable. 
 
 With the latter kind of wound just described there is a 
 far greater general reaction and a higher degree of discom- 
 fort or of pain, and there is a greater likelihood of compli- 
 cations, grave or trivial, such as phlebitis, thrombosis, the 
 late discharge of buried ligatures or sutures, or the recur- 
 rence of the condition which originally required operation. 
 
 Surgery should be a merciful art. The cleaner and the 
 gentler the act of operation, the less the patient suffers, 
 the smoother and the quicker his convalescence, the more 
 exquisite his healed wound, and the happier his memory
 
 50 ESSAYS ON SURGICAL SUBJECTS 
 
 of the whole incident, to him probably one of the most 
 important in his life. The results of our ritual are there- 
 fore expressed not only in the mortality where the differ- 
 ence may be slight but also in the quality of the healing 
 of the wound, and in the quality of the recovery from 
 the operation, in respect of security, rapidity, smoothness, 
 completeness, and finality. 
 
 In the ritual of a surgical operation the mysteries are 
 imposed not only upon the high priest and upon the 
 acolytes, but upon the congregation also. Every visitor 
 to an operation theatre takes a part, however remote, in 
 the operation. He is gowned, masked, and his head cov- 
 ered with a cap nowadays in all clinics. But dirty boots 
 and soiled trouser legs, conveying mud, dust, and faecal 
 matter from the streets, are often unnoticed. If the 
 wearer of them moves about the theatre freely, or goes 
 from one theatre to another, the organisms carried in the 
 drying filth are scattered broadcast, as the simplest ex- 
 periment will prove. Large canvas overalls for the boots 
 and the lower part of the leg, tying just below the knee, 
 as a sort of legging, will afford ample and secure covering 
 to this possible source of infection. 
 
 The surgeon and his assistants (the fewer the better) 
 should, of course, change all their external garments before 
 operation. The trousers and coats we all wear are very 
 dirty. What would a pair of tennis flannels look like at 
 the end of a week's wear in London? Our everyday 
 darker garments do not show the same marks, but they 
 carry the same dirt. White sterilized trousers, clean 
 white shoes or overshoes, sterile coat, cap and mask, all 
 are necessary for the perfect outfit. They are much more 
 comfortable to wear in a theatre adequately warmed, and 
 there is a feeling of much greater freshness, both before and
 
 THE RITUAL OF A SURGICAL OPERATION 51 
 
 after an operation, when garments are changed. But I am, 
 no doubt, like Jonah preaching to a converted Nineveh. 
 All these matters are now a part of our daily routine. 
 
 The method of the preparation of our hands and arms 
 is important. It is still a common thing to see hands 
 washed in a basin of still water. The moment the hands 
 are soaped and rinsed the water is polluted by the dirt 
 washed off the skin. If the washing is continued it is 
 obvious that the hands are being constantly re-infected 
 from the contaminated water. If the water is emptied 
 away, and fresh poured in, the basin, being polluted by 
 the water it formerly contained, defiles the fresh water. 
 And it is really not uncommon to see a piece of soap used 
 to lather the hands, laid down, and picked up again, 
 regardless of the fact that each contact of the soap with 
 something else is a possible method of soiling it. The 
 best of all plans is to wash under running sterile water. 
 Some years ago I had water-tanks made, to hold five 
 or six gallons, fitted with a dispensary tap, and placed 
 over gas-coils, so that the water contained in them might 
 be boiled. When the water boils the tap is turned, and 
 about a gallon of water allowed to run through to sterilize 
 the tap, on the end of which a boiled plug is fitted until 
 the time comes for use. In a hospital installation it is 
 easy to arrange for the tanks to be sterilized by steam and 
 to be cooled by water running through a coiled pipe in the 
 tank. Water can be boiled for a quarter of an hour, 
 and cooled sufficiently for use in five minutes. Over the 
 tank is placed a tap for refilling. 
 
 Almost all commercial soaps are sterile. The outer 
 surface, of course, may be polluted, but when this is washed 
 or scraped away the exposed fresh surface of the soap is 
 sterile. Two methods of using soap are simple and satis-
 
 52 ESSAYS ON SURGICAL SUBJECTS 
 
 factory: to use a tablet of any household soap which 
 has been lying in a solution of acrosyl for half an hour; 
 or to sterilize some green soft soap in a flat dish in the 
 autoclave, and to rub off, time after time, with a sterile 
 gauze swab, enough of the soap to form a good lather. 
 After washing for not less than fifteen minutes the hands 
 should be gently rubbed with gauze wet in spirit and 
 biniodide solution, or in a solution of acrosyl, which is 
 the antiseptic least likely to damage the skin. There is a 
 great difference in the facility with which a hand can be 
 cleaned; some rough, chapped hands, coarsened by anti- 
 septics, clean with great difficulty; smooth hands, well 
 cared for, are sterile very soon. A surgeon's hand should 
 be always carefully tended; nails should be kept clean 
 and short and smooth, and the skin like satin. Once a 
 week or so a visit to a manicurist is desirable. 
 
 Gloves are almost universally worn during operations. 
 I know only three surgeons the world over who are in the 
 first rank who do not constantly wear gloves during opera- 
 tions. The arguments in favour of their use are un- 
 answerable. A glove properly prepared is sterile, and 
 remains so if put on the hand without its outer side being 
 touched by any except the glove of the other hand or a 
 piece of sterile gauze. With practice it is rare to puncture 
 a glove except in bone operations, and for these it is 
 often an advantage to wear thin cotton gloves over the 
 rubber. If a puncture does occur, a finger stall may be 
 put on, or the glove changed in a few seconds. The bare 
 hand is difficult to sterilize in some cases; it is almost im- 
 possible to keep it sterile throughout an operation, as the 
 silk- thread experiment of Kocher shows; if it is infected 
 during an operation it can certainly not be used uncovered 
 again with safety during that operation.
 
 THE RITUAL OF A SURGICAL OPERATION 53 
 
 A surgeon may say that he uses gloves only for septic 
 cases. Does he always know when an operation, or any 
 stage in it, is to be septic? If he inadvertently soils his 
 hand when a septic area is unexpectedly discovered, does 
 he then put on gloves? Has he them always ready to 
 wear? Or does he use an antiseptic in the hope of com- 
 bating the infection which he spreads with every touch? 
 Is it not the simpler, safer, more certain way to wear 
 gloves w r hich are certainly sterile, and to change them 
 when there is any doubt as to their defilement? 
 
 But about the wearing of gloves a good deal may be 
 said. Often they are a mere fetish. How often are 
 gloves put on without their outer surfaces being touched 
 or stroked by a bare hand? How often are they consid- 
 ered rather a protection for the surgeon than for the 
 patient? I have seen gloves put on carefully, and the 
 gloved hand then used to palpate an abdomen imperfectly 
 smeared with iodine. I have seen a blanket which covered 
 a patient's legs pulled up towards his body by a gloved 
 hand which a few minutes later was inside the patient's 
 abdominal cavity; and I have seen cleaned hands gloved 
 and unclean forearms left bare on more than one occasion. 
 I have seen gloves used in the earlier stages of operation, 
 and removed when a difficulty arose in, say, an operation 
 upon an enlarged thyroid gland, or an operation for hernia. 
 This is a technical sin of the gravest kind. Gloves may be 
 sterilized by boiling, or be placed in the autoclave with the 
 dressings and swabs and used dry. The advantage of the 
 dry glove is that it is more comfortable to wear during a 
 long list of operations, and that the hand being covered 
 by a dry sterile powder is kept free from moisture. A 
 chance puncture of the glove does not involve the escape 
 of a possibly contaminated fluid into the wound. Gloves
 
 54 ESSAYS ON SURGICAL SUBJECTS 
 
 should be kept on the hands till the dressing of the wound 
 is complete, and until the coat and sleeves are removed. 
 If gloves are properly sterlized and properly put on, the 
 covered finger may be used to explore a knee-joint or 
 anywhere else with impunity. 
 
 The "knife-and-fork" method of operating, in which 
 only instruments are handled for every purpose, including 
 the tying of ligatures, is a confession that the gloves cannot 
 be trusted by the operator. If the bare hand is used during 
 operations there is a risk which approaches certainty that 
 the wound will be contaminated. This contamination 
 may be lessened in its malignancy by the immediate 
 application of antiseptics, or by the free and frequent 
 washing of the hands in a bactericidal solution; but the 
 results either of mild contamination or of the irritation 
 of antiseptics in the wound are expressed in those qualities 
 of its healing to which I have referred. Many years 
 ago, before I began to use "tetra" cloths to cover the skin 
 around the wound up to its edges, we found that when 
 cultures were taken from a wound they became progres- 
 sively more numerous the longer the incision remained 
 open; but many an infected wound healed by what we 
 were then content to call ' 'first intention. ' ' We soon learnt 
 that there was a degree of "clinical sterility" of a wound 
 which was far removed from the "absolute sterility" which 
 it should be our endeavour always to secure, and which 
 alone allows of "perfect" flawless healing and a convales- 
 cence free from suffering. Above the gloves worn by all 
 those directly engaged in the operation no bare arm 
 should be seen. Either a long-sleeved gown should be 
 worn, or sleeves which fit firmly round the wrist, there to 
 be covered by the cuff of the glove. 
 
 Among the more important questions involved in the
 
 THE RITUAL OF A SURGICAL OPERATION 55 
 
 ritual of a surgical operation is that concerned with the 
 preparation of the skin. The skin does not always, indeed 
 does not often, harbour organisms, either on the surface 
 or in the depths of sweat or sebaceous glands, of any 
 special septic malignancy; but one can never be certain 
 to what contact the skin has been subject, and therefore 
 it is always uncertain whether septic organisms or spore- 
 bearing bacilli are present or not. It is always necessary 
 so to prepare the skin for a wide area around the wound to 
 be inflicted that, so far as is humanly possible, no con- 
 tamination of the wound shall be caused from this source. 
 Infection may be conveyed to the skin of the surgeon's 
 hands by the examination of discharging wounds, by 
 rectal or vaginal or buccal examinations, or during an 
 operation. This possibility should be prevented by the 
 avoidance of any contact with patients, in these circum- 
 stances, unless gloves are worn. The principle of "ab- 
 stinence" is the safest: the surgeon abstains from soiling 
 his hands by contact with any potentially infective agent. 
 It is exceedingly difficult so to sterilize the human skin 
 that it will long remain sterile, as all the experiments 
 conducted in recent years have shown. When a germi- 
 cidal solution is applied to the skin, there is a "clean fight," 
 so to speak, between the solution and the germs lying in 
 or on the skin. The value of the solution as a germicide 
 is therefore easy to test, and results obtained by these 
 experiments may be accepted as of great value. It is 
 far otherwise when a gennicidal solution is applied to a 
 wound, especially to an open wound a few days old, 
 wherein reparative processes have begun. In such a 
 wound an innumerable number of side contests are 
 introduced; it is no longer a fight between a germ and a 
 germicide. There are the cellular and the fluid contents
 
 56 ESSAYS ON SURGICAL SUBJECTS 
 
 of the wound discharge, and the various actions and 
 reactions produced among them, the wound surfaces, the 
 dressings, and the germicide all to be taken into account. 
 It is a matter of interest to consider w r hether we do not 
 go far astray when we assess the value of a germicide in an 
 experiment in vitro, and then expect an equivalent germi- 
 cidal action to be produced in an open wound. It is, I 
 think, very doubtful whether the "antiseptic" action 
 produced by the addition of a particular chemical sub- 
 stance to a wound is due to those properties which it 
 possesses as a bactericide. It probably possesses other 
 properties also which are not strictly related to its germi- 
 cidal power. But in the case of the skin no such perplex- 
 ing problems arise. The efficacy of any germicide can be 
 tested quite easily ; and the results of experiments should 
 here guide our practice. A surgeon may say that he is 
 satisfied with the healing of his wounds when he might 
 quite easily have better results by using better methods 
 of skin sterilization. By clinical experience, which is 
 tedious and lengthy, we may at last realize the value of 
 skin disinfection, which we might have determined at 
 once by experiment. By experience we find a short way 
 by a long wandering. 
 
 What are the requirements for an ideal skin disin- 
 fectant? It should be cheap and easily accessible, simple 
 in its application, non-irritant, capable of penetrating the 
 skin to some depth; it should be effective in destroying in 
 a short time all of the organisms which are found on or in 
 the skin, and it should do nothing to prevent or delay the 
 clean and speedy healing of the wound. 
 
 The skin disinfectant most commonly employed is 
 iodine. It is applied in varying strengths, and in different 
 vehicles spirit, chloroform, acetone, benzine, etc. The
 
 THE RITUAL OF A SURGICAL OPERATION 57 
 
 tincture of iodine is the form which is most often used. 
 Both experimentally and clinically the method is clearly of 
 the second rate. The work of Tinker and Prince, Hunter 
 Robb, Stan ton, and others, shows that even when the iodine 
 is allowed to remain on the skin which is tested, sterilization 
 is not always indicated by the culture tube; if the iodine is 
 removed by a solution of potassium iodide, and the skin 
 washed with sterile water and examined, infection is 
 demonstrable in over 50 per cent, of cases. A very large 
 proportion of the iodine used often disappears from the 
 skin before the operation is completed. There is nothing 
 then to recommend iodine but the ease and rapidity with 
 which it can be applied and its colouring of the skin; its 
 efficacy is far less than is required, and it is a powerful 
 irritant. Iodine, to be effective, must be applied on a dry 
 skin, which often means a dirty skin. I have more than 
 once seen a smear of iodine applied over grime and filth 
 that could not be sterilized by a dozen similar applications. 
 I have used iodine myself on a great many occasions, and 
 have given it a fair trial; I have seen it in a very large 
 number of clinics; yet I have very rarely seen a wound 
 heal with all those attributes which are necessary before 
 one is entitled to say that it is "perfect" when iodine alone 
 has been applied. Picric acid in alcoholic solution of a 
 3 per cent, or 5 per cent, strength gives better results than 
 iodine; but it does not penetrate deeply, and it is not of 
 sufficient bactericidal value. The wounds are, again, not 
 up to the highest standard in a large number of cases. 
 
 Brilliant green is perhaps the most effective of all the 
 aniline group of antiseptics when applied to the skin. 
 
 By far the best method of preparing the skin that I 
 have ever used and I have tried and tested many 
 is carried out in three stages: (1) Abundant washing with
 
 58 ESSAYS ON SURGICAL SUBJECTS 
 
 soap and water, preferably ether soap ; (2) gentle friction 
 with biniodide of mercury and spirit solution 1 : 500 ; (3) 
 drying; followed by the application for two to three 
 minutes of Harrington's solution. When the towels are 
 fixed round the operation area a further application of 
 Harrington's solution is made; and throughout all opera- 
 tions the skin is covered with towels so that no friction of 
 the hands against it is possible. It would be well if 
 surgeons the world over took a little more pride in the 
 wounds they inflict. The appearance of a wound is often 
 the best index to the quality of the work that has been 
 done throughout the operation. 
 
 The towels, which should surround the operation area 
 as closely as possible, are fixed to the skin by clips. On 
 the surface of the skin left exposed a series of tiny 
 scratches are made by a very thin needle, at right angles 
 to the proposed line of incision. These are for the purpose 
 of indicating where the stitches are to be introduced when 
 the wound is sutured. Unless there is a mathematical 
 accuracy of apposition there is never perfect beauty in a 
 wound or scar, and accuracy of apposition is difficult or 
 impossible unless some method of this kind is adopted 
 to secure it. 
 
 In so far as the actual operation is concerned, it is, for 
 the reasons I have given, essential to avoid contact with 
 the skin of a patient as much as possible. The hands 
 should not touch the skin at all, viscera should not be 
 allowed to lie upon it, and the rubbing of instruments 
 against it must be avoided. As soon as the incision is 
 made, cloths of several thicknesses of gauze or towelling 
 are fixed to the skin edges and dip well into the wound. 
 If these "tetra" cloths lie loosely on the parts around the 
 wound, they ruffle up during the movements of the sur-
 
 THE RITUAL OF A SURGICAL OPERATION 59 
 
 geon's hands. If powder is dusted on the under surface 
 of them it is soon found to lie in the wound. The towels 
 must, therefore, be held at points distant from the wound, 
 so that they are kept stretched and fixed throughout the 
 operation. When they are removed at the conclusion of 
 the operation, the skin covered by them is washed over 
 with spirit and with Harrington's solution before any 
 stitches are inserted. 
 
 The wound is made by a firm, clean sweep of the knife. 
 Any bungling here makes an irregular, ugly wound. A 
 good many of the scalpels made nowadays are peculiarly 
 unfitted for their work. I use only two patterns: one 
 with a deep belly, made for me by Stille of Stockholm 
 originally, and the other Stiles' pattern, which is used for 
 all dissections. All vessels are clipped if possible, as in 
 a hernia operation, before being cut, but certainly the 
 moment they are cut. If blood leaks into a wound it 
 stains the tissues, and makes subsequent dissection along 
 the "white line" very difficult. 
 
 I say that "vessels" are clipped. Most of the clips 
 made seize not only the vessels but a mass of tissue 
 surrounding them. When ligatures are applied, all this 
 tissue is strangled in the ligature, and has to be digested by 
 leucocytes in the wound. The tips of artery clips should 
 be narrow almost pointed and should seize the very 
 smallest possible portion of tissue with the vessel. If 
 dissection is carried on in a wound, as when glands of the 
 neck, or of the breast in a case of carcinoma, are removed, 
 gentle traction in one direction by the surgeon, and in the 
 opposite by his assistant, will reveal a fluffy layer of thin 
 areolar tissue, the "white line" as I always call it, along 
 which dissection can proceed very easily and quickly, and 
 with the immediate disclosure of all the vessels which must
 
 60 ESSAYS ON SURGICAL SUBJECTS 
 
 be seized. This involves the application of many clips, 
 but the wound should always be kept dry and unstained 
 by blood. Kocher was accustomed to put out twenty 
 dozen clips for a goitre operation, and on many occasions 
 he seemed to use most of them. It should be our ideal 
 to complete such an operation, which in my student days 
 was often one involving much loss of blood, without 
 staining the towels round the wound. 
 
 Though traction is necessary in gland and goitre op- 
 erations, it must be avoided in abdominal work. There 
 every pull means a pain. I dislike abdominal retractors 
 intensely. The forcible and merciless retraction of the 
 abdominal wall throughout a long operation cannot fail 
 to cause shock and suffering afterwards. The best 
 retractor is the gentle light hand of a well-trained as- 
 sistant, used mercifully when it must be used at all. But 
 with adequate incisions, retraction is very little needed 
 during the greater part of most operations. 
 
 Dissection may be carried out in two manners: by 
 the knife or by "gauze stripping." If by the knife, the 
 movements should be short, sharp, close together, so that 
 if recorded on a moving drum the picture would resemble 
 a "feather edge." And the knife must be sharp. Big, 
 heavy, clumsy movements with a dull knife hurt the 
 patient, and leave the parts less fitted to heal. Through- 
 out the operation there must be no undue exposure of 
 parts. In a large dissection, such as that required in re- 
 moval of a cancer of the breast, the dissection extends from 
 the axilla to the umbilicus, and from the opposite pectoral 
 muscle over the latissimus dorsi. With skin flaps turned 
 back, the bared area is very extensive. It should never 
 be seen as a whole. As one part of the dissection is com- 
 pleted, hot moist mackintosh cloths are placed over the
 
 THE RITUAL OF A SURGICAL OPERATION 61 
 
 raw surface to prevent drying and chilling, and the chance 
 of contamination. Similarly, in abdominal work, only that 
 part of the operation field should be seen with which the 
 operator is at the moment engaged. There is no need in 
 the operation of gastro-enterostomy, for example, for any- 
 thing to be outside the abdomen during the suturing of 
 the viscera except that small part of each which is em- 
 braced by the clamps. The patient is accustomed to keep 
 his own viscera warm, and he should still be allowed to do 
 so. Crile's work has shown, to my mind conclusively, 
 the need for avoiding cooling or drying of wound surfaces. 
 
 All the instruments used during the operation are, of 
 course, sterilized by heat; but it is important to remember 
 that contamination may occur during an operation, and 
 therefore the various clips, scissors, retractors, or other 
 instruments should be resterihzed as often as is necessary. 
 If, for example, a pair of scissors are used to open the 
 intestine in a case of gastro-enterostomy or colectomy, or 
 needles to suture viscera together, they are at once dis- 
 carded, and never used again till they have been boiled. 
 The mucosa may be sterile in a case of gastro-enterostomy , 
 but one can never be certain, and it is safer always to 
 assume that any possibly infected tissue is infected. 
 
 In operations for malignant disease, frequent steriliza- 
 tion of instruments is most necessary. For example, in 
 removing a breast for carcinoma, many surgeons, of whom 
 I am one, adopt the method suggested by Rodman and 
 Willy Meyer, and complete the axillary dissections first. 
 There are many advantages in so doing which need no 
 mention now. Every instrument used in this dissection 
 knife, clips, scissors may possibly be brought into contact 
 with a cancer cell. When once used it is therefore laid 
 aside, and not taken up again till it has been reboiled.
 
 62 ESSAYS ON SURGICAL SUBJECTS 
 
 Cancer cells, as Ryall and others have shown, can be 
 grafted on to the patient's own tissues and develop a new 
 deposit of cancer. It is obvious that the graft may be 
 conveyed to any instrument, or on the gloved hand if it 
 is at work in the wound. In all operations I have a red 
 handkerchief placed on the table which lies over the legs 
 of the patient. As soon as any instrument is soiled I 
 place it on this danger spot, and it is at once removed by 
 the nurse to the sterilizer. 
 
 As regards the material used for ligatures and sutures 
 which must remain within the wound, certain conditions 
 are essential. Such material should, ideally : (1) Achieve 
 its purpose be sufficient to hold parts together, close a 
 vessel, etc.; (2) disappear as soon as its work is ac- 
 complished; (3) be free from infection; and (4) be non- 
 irritant. 
 
 The only material which can be made to fulfil these 
 conditions is catgut. Catgut can be sterilized perfectly. 
 The method of Claudius, which directs that the catgut 
 should be soaked in a solution consisting of iodine 1 per 
 cent, and potassium iodide 1 per cent, in water, ignores 
 the fact that with such a proportion of iodide of potassium 
 all the iodine is not dissolved ; much of it lies inert at the 
 bottom of the vessel. I use a solution made in accordance 
 with their atomic weights, iodine in a strength of 1 per 
 cent, and iodide of potassium in a strength of 1.75 per 
 cent. ; the whole of the iodine is then taken up, a darker 
 and stronger solution results, and catgut soaked in this 
 for ten days or more is almost black in colour, and so 
 strongly permeated by iodine that it is exceedingly difficult 
 to infect it. I have never known any surgeon use silk 
 and not have trouble from it. Silk for ligatures is not 
 necessary, for catgut will securely tie any vessel. Silk for
 
 THE RITUAL OF A SURGICAL OPERATION 63 
 
 intestinal sutures is not necessary. Certainly I have not 
 used any for fifteen years, and I have now discarded linen 
 thread for all but the anastomoses after colectomy. An 
 unabsorbable suture used to effect the junction in gastro- 
 enterostomy is possibly a factor causing the development 
 of a jejunal ulcer. But thick chromic catgut also will 
 remain for years at a suture line in such a case. In one 
 patient I have found a piece of chromic catgut over 
 two inches long dangling at the gastrojejunal opening 
 three years and nine months after the anastomosis had 
 been made. It is, of course, as I have before pointed out, 
 the sero-serous suture which is the offender in such in- 
 stances. The inner mucous suture, no matter of what 
 material, is soon loosened and escapes. 
 
 Probably we all use more sutures than are necessary in 
 intestinal anastomoses. In urgent cases I have more than 
 once used a single Connell suture with perfect success. 
 But in surgery, in order to be certain that you have done 
 enough, it is generally prudent to do more than is neces- 
 sary. Over and over again I put in an additional stitch 
 here and there. I know it is not really needed, but I call 
 it my "hypnotic" stitch; for I sleep better at night when 
 I know it is there. 
 
 The most important person present at an operation is 
 the patient. This is a truth not everywhere and always 
 remembered. It is our duty to make the operation 
 as little disagreeable as possible for him. To many 
 patients it is a dreaded ordeal. Our patients today are 
 terrified by the tradition that clings to the word "opera- 
 tion," a tradition started in the days when it must indeed 
 have been a terrible procedure, without anaesthetics other 
 than those stupefying drugs, alcohol and tobacco, with 
 patients strapped down or held by assistants, and all the
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 other horrible accessories. Today an operation can, and 
 should, be made a very simple matter, devoid entirely of 
 anything repellent or disheartening. 
 
 The preliminary use of scopolamine, atropine and 
 morphine, or of omnopon is a very valuable help. One 
 dose of rig- gr. atropine and about y^ or ^ gr. scopol- 
 amine and i or gr. morphine is needed, according to the 
 patient's age, size, etc. This is given about three- 
 quarters of an hour before operation. In a private 
 hospital the blinds should then be drawn down, the room 
 darkened, and the patient encouraged to sleep. No talk- 
 ing is allowed. The nurse remains in the room, but is 
 warned not to speak, and, of course, no friends are then 
 permitted to see the patient. When the patient is taken 
 to the operation theatre as quietly as possible, a towel 
 covers the eyes and the operation room itself is dark. 
 No conversation is allowed in the theatre, and only the 
 anaesthetist and one nurse, or possibly two nurses, remain. 
 Everything is kept as quiet and orderly as possible. 
 About one-third of the patients subsequently say they 
 have little or no recollection of going to the theatre or of 
 taking the anaesthetic. All abdominal cases are treated 
 by Crile's method of quinine and urea injections into the 
 parietal peritoneum, and into the nerve-trunks running 
 to the area in which the operation takes place. There is 
 no doubt as to the diminution of pain thereby resulting. 
 With shock we are not much concerned. There are very 
 few occasions indeed when shock results from an ab- 
 dominal operation properly conducted, when the patient 
 is kept warm on the table by one device or another, and 
 when the gentlest handling, the most careful hsemostasis, 
 and adequate protection of parts have been exercised. 
 
 Every detail in every operation is of importance, and
 
 THE RITUAL OF A SURGICAL OPERATION 65 
 
 should be conceived, practised, and tested with unweary- 
 ing patience by the operator himself, and by him in 
 conjunction with all his assistants. Was it riot Michael 
 Angelo who first said that success depends upon details, 
 but success is no detail? In surgery, at least, success may 
 well depend upon the scrupulous, exacting, and unceasing 
 supervision and close scrutiny of every smallest incident 
 of procedure. In respect of surgical work there may be 
 some truth in Blake's assertion that ah 1 excellence is in 
 minute particulars. Surgery is nowadays no longer the 
 work of an individual, but of a "team" in which every 
 member plays his exact part, in which all contribute to 
 success, and in which each may bring about disaster. The 
 well-trained team should display that mastery which is 
 implied by ease in smooth and efficient action. In every 
 phase of its work there should be not merely the casual 
 observance of a ritual the meaning of which is lost and the 
 deeds of which are only a faded counterfeit, but acts of full 
 devotion to principles which have been tried and proved, 
 acts which are the witnesses to a living and perfect faith. 
 
 It is, of course, a platitude to say that a good surgeon 
 is not merely one who operates well. The qualities re- 
 quired to make our ideal surgeon are many: gifts of 
 character, leadership, wisdom even worldly wisdom 
 compassion, and the finest technical skill. In respect of 
 the latter we remember that surgery is not only a science 
 but an art, work demanding the highest craftsmanship, 
 and a knowledge of all the "tricks of the tools' true play." 
 
 In all the movements of the surgeon there should be 
 neither haste nor waste. It matters less how quickly an 
 operation is done than how accurately it is done. Speed 
 should result from the method and the practised facility 
 of the operator, and should not be his first and formal 
 
 5
 
 66 ESSAYS ON SURGICAL SUBJECTS 
 
 intention. It should be an accomplishment, not an aim. 
 And every movement should tell, every action should 
 achieve something. A manipulation, if it requires to be 
 carried out, should not be half done and hesitatingly done. 
 It should be deliberate, firm, intentional, and final. 
 Infinite gentleness, scrupulous care, light handling, and 
 purposeful, effective, quiet movements which are no 
 more than a caress, are all necessary if an operation is to 
 be the work of an artist, and not merely of a hewer of 
 flesh. For every operation, even those procedures which 
 are now quite commonplace should be executed not in the 
 spirit of an artisan who has a job to get through, but in the 
 spirit of an artist who has something to interpret or create. 
 An operation should not only bring relief or health to the 
 patient, but should give a glow of keen delight to the 
 artist himself, a thrill of joy and a sense of complete 
 satisfaction to a critical spectator. 
 
 Ours has been a necessary profession ever since man's 
 body was subject to enmity and casualty. All who prac- 
 tise it will need the gifts of which Thomas Fuller spoke 
 "an Eagle's eye, a Lady's hand, and a Lion's heart." Of 
 all of us who labour honestly may it at last truthfully be 
 said, as it was said of James IV of Scotland, "Quod vulnera 
 scientissime tractaret" "He was most skilful at the 
 handling of wounds."
 
 THE DIAGNOSIS AND TREATMENT OF 
 CHRONIC GASTRIC ULCER* 
 
 AROUND the subject of gastric ulcer a very extensive 
 literature has accumulated. Every country, and a host of 
 authors, have contributed to it, until there must be many 
 who doubt whether anything really fresh or important 
 remains to be said. Yet I hold a firm belief, based upon 
 an experience the length of which I dread to contemplate, 
 that no small part of what is written requires ruthless 
 revision in the light of the modern methods of inquiry 
 conducted by the radiographer and the surgeon. The 
 wealth of teaching in the text-books is too often imper- 
 sonal, and represents rather a legacy flowing from one's 
 ancestors than a fortune newly won by hard endeavour. 
 The heritage in respect of gastric ulcer is heavy enough, 
 but not all of the securities are worth their face value. 
 
 A gastric ulcer is, of course, an ulcer occurring in the 
 stomach. During development the stomach is differen- 
 tained as one part of the foregut from that other part 
 which forms the duodenum as far down as the ampulla of 
 Vater. The foregut terminates at the point of entrance of 
 the ducts of the liver and pancreas ; at the end of the second 
 month of fetal life the pylorus marks off the stomach from 
 the duodenum. When development is complete it is, as a 
 rule, easily possible in all periods of life to distinguish the 
 stomach from the duodenum. On palpation the pyloric 
 muscle and valve are felt at once. Exactly in the line 
 
 * A paper read at the opening of the Session of the Harveian Society, October 
 23, 1919. Reprinted from the British Medical Journal, December 13, 1919. 
 
 67
 
 68 ESSAYS ON SURGICAL SUBJECTS 
 
 of the pylorus a thin white line is to be seen on careful 
 examination; the line becomes clearer if in the living 
 subject the pylorus is held forward by a finger and 
 thumb placed one on the stomach, the other on the 
 duodenum, and closed to meet in the pylorus. In close 
 proximity to the "pyloric white line" is a vein, the 
 "pyloric vein," which begins at or near the middle of the 
 anterior surface of the pylorus and runs downwards to 
 the greater curvature. The "pyloric vein" is constant, 
 its arrangement variable. It may be single and large, 
 short and branched, or long with only very slender 
 branches; it may be double; it may or may not be met 
 by a smaller vein running up towards the lesser curvature; 
 it may lie on either side of the pyloric white line. The 
 perfectly fair criticism has been made against the accept- 
 ance of this vein as a landmark, that veins are very 
 irregular in their arrangement, position, and distribution, 
 and that nowhere else in the body is the position of a 
 vein so constant as this is asserted to be. And it must 
 be frankly admitted that there is a very small number of 
 cases in which the venous arrangment is such that no 
 accurate localization of the pylorus is possible from a 
 surface inspection. But there is no landmark in the 
 body that is invariable. For many years past I have 
 drawn the position of this vein as seen during an operation 
 while the parts were under inspection, and it is quite safe 
 to say that in at least 90 per cent, of the cases the markings 
 I have mentioned may be accepted as accurate. Latarjet 
 (Lyon Chirurgical, 1911, vi, 337), after a research con- 
 ducted for the purpose of deciding the value of the vein 
 as an accurate landmark, concludes in favour of its 
 acceptance. 
 
 An ulcer occurring on the proximal side of this vein is a
 
 CHRONIC GASTRIC ULCER 69 
 
 "gastric ulcer"; an ulcer occurring J or J inch or more 
 beyond it is a "duodenal ulcer." It is not merely a matter 
 of academic interest to distinguish them; their symptoms 
 are sufficiently distinct to allow an accurate diagnosis of 
 duodenal ulcer to be made with remarkable constancy; 
 their complications and sequels in respect of perforation 
 and haemorrhage are very different; cancer develops 
 often upon the base of a gastric ulcer, and almost never 
 upon the base of an ulcer in the duodenum. Gastric ulcer 
 is a disease of comparative rarity; its diagnosis from the 
 clinical evidence alone is difficult; its mimicry by other 
 conditions extremely frequent. These statements may 
 not find a ready acceptance everywhere. For if the text- 
 books of medicine, or the special works of distinguished 
 authors are read, or if the diagnosis made in the out- 
 patient medical clinics are reviewed, it will be found that 
 there is a general agreement that gastric ulceration occurs 
 frequently, and that its symptoms are of a kind hardly 
 admitting of doubt or difficulty in diagnosis. I have 
 spent a great deal of time in reading almost everything 
 to which I could obtain access that has been written 
 about gastric ulcer, and I am compelled to say that when 
 the statements univeraslly made are tested by the ex- 
 perience gained in the operation theatre they are found to 
 be inaccurate. My contention is that a full, clear, and 
 truthful description of the symptoms of gastric ulcer is 
 rarely given, and that the conditions described as "gastric 
 ulcer" are in the majority of cases indicative of other 
 diseases. 
 
 What are the symptoms of gastric ulcer, and how may 
 the diagnosis be made? 
 
 Ulcer of the stomach occurs twice as often in men as in 
 women; its chief symptom is pain. All the attributes of
 
 70 ESSAYS ON SURGICAL SUBJECTS 
 
 this symptom merit and must receive the closest scrutiny. 
 The chief attribute is, I think, regularity. In all cases of 
 gastric ulcer there are periods of intermission, longer or 
 shorter, at one period of the year or another; but when 
 the attacks are present the pain which is then the chief 
 feature always displays regularity. It comes after all 
 meals, even light meals; it is not present after breakfast on 
 one day, after dinner on another, and absent entirely on 
 another day. If a meal is eaten, pain during the attack 
 follows invariably. The interval between the taking of 
 the meal and the onset of pain is fairly constant. As a 
 rule the earlier the pain is felt after a meal, the nearer is 
 the ulcer to the oesophagus. That is to say, if pain 
 comes, regularly, one or one hour and a half after a meal, 
 the ulcer that causes it is in the stomach, it is a "pre- 
 pyloric" ulcer. If pain comes two, three, or four hours 
 after a meal the ulcer lies generally beyond the pylorus. 
 This period of relief from pain after a meal is constant 
 and invariable, both in gastric and duodenal ulcers, until 
 stenosis, subacute perforation, or the formation of crip- 
 pling and embarassing adhesions takes place. These con- 
 ditions may lead to a delay in the time of the appearance 
 of the pain in cases of gastric ulcer, or to the hurried 
 appearance of the pain in cases of duodenal ulcer. 
 
 In over three cases in five of gastric ulcer, seen during 
 operation, the pain came within one and a half hours of 
 the taking of food ; in rather more than four cases in five 
 of duodenal ulcer the pain appeared two hours or more 
 after food. The pain in cases of gastric ulcer very often 
 disappears after an hour, or even less, and may be com- 
 pletely relieved, indeed, it generally is, before the next 
 meal is due. The pain of duodenal ulcer, on the other 
 hand, appearing later, generally persists, often with a
 
 CHRONIC GASTRIC ULCER 71 
 
 slowly increasing severity, until the meal is taken. The 
 character of the meal influences the pain. A generous 
 meal of heavy foods causes severe pain to appear at an 
 earlier time in gastric ulcer; it delays the appearance of 
 the pain in cases of duodenal ulcer. Smaller meals of 
 soft, pultaceous food, easy of digestion and easily pro- 
 pelled, produce less pain, and the interval of relief brought 
 by the food is longer. An indiscreet and hasty meal, espe- 
 cially of fruits, or salads, or pastry, may give instant and 
 grievous pain. A bland and blameless diet taken in small 
 quantities at brief intervals may reduce the chances of 
 pain appearing, or even afford complete relief. In a small 
 proportion of cases pain may not be influenced by food in 
 the manner and to the extent now described. When the 
 ulcer is near the cardia there may be no relief from taking 
 food, or pain may immediately be made worse; each of 
 these features is present in approximately 4 per cent, 
 of the cases. 
 
 The pain is variously described: it is a deep, "boring," 
 "burning," or "aching" pain; there may be "gnawing" 
 or a sense of acidity and a desire for food or warmth. The 
 pain in a majority of cases is said to be on the left side or 
 high in the epigastrium; in some severe types there may 
 be great complaint of pain in the back. In twenty-three 
 cases in which there was a deep excavation in the pan- 
 creas consecutive to a subacute perforation of the ulcer on 
 the lesser curvature or posterior wall of the stomach, 
 seventeen patients complained bitterly of the intolerable 
 aching in the back. As we know, many patients attacked 
 with acute pancreatitis suffer most from pain in the back, 
 and it is an old observation and an accurate one that a 
 deep eroding ulcer of the pancreas may also produce this 
 most distressing symptom.
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 The position of the ulcer, its freedom from adhesion to 
 neighbouring parts, and its size, all seem to affect the 
 type of pain, its periods of latency, and its time of onset 
 after meals. When ulcers are small and seated high up on 
 the lesser curvature, or just on the posterior surface, the 
 symptoms are shorter in duration, but more prone to 
 recurrence. They are often, as we learn from the radio- 
 graphic examination, attended by severe forms of local 
 spasm, which are responsible for the sensations of dis- 
 tension, weight, and pressure, which appear to accompany 
 these ulcers more often than those of other types. If the 
 ulcer is large, excavating the liver, or burrowing deeply 
 into the pancreas, or if it is fixed by firm broad adhesions 
 to the abdominal wall or the liver, the symptoms are less 
 likely to show those intermissions which are so charac- 
 teristic of the earlier stages. If, therefore, in the history 
 of an individual case we learn that the periods of freedom 
 from suffering have become by degrees shorter, and have 
 finally vanished, we may often predict that some of the 
 conditions named are present. If, in addition, there are 
 wasting and especially anaemia, we may be very suspicious 
 of the onset of malignant disease. 
 
 Relief from pain is obtained not only from food, but 
 from alkalies, sodium carbonate, "mint drops," or from 
 vomiting. Lavage of the stomach often gives great 
 temporary relief. 
 
 The fact that the severity of the pain is so often 
 mitigated by food accounts for the fact that many 
 patients do not lose weight, or may actually gain weight 
 during an attack. Patients with gastric ulcer recognize 
 that heavy meals three times a day bring their own 
 punishment. Lighter meals are taken at shorter intervals, 
 and the total amount of food, much of it of high value,
 
 CHRONIC GASTRIC ULCER 73 
 
 is accordingly far greater than that usually consumed. 
 Weight is therefore gained. 
 
 About one-fifth of the patients who are found to have 
 gastric ulcers complain not only of pain, but of great 
 prostration, feebleness, or lassitude coming on just at the 
 time when the pain is due. On close enquiry this most 
 distressing symptom may be found to have preceded the 
 experience of pain by weeks or months. The periodicity 
 of the two is identical. 
 
 It is not possible to emphasize unduly the importance 
 of ascertaining all these various modifications of the one 
 symptom, pain. The constancy of the sequence food, 
 comfort, pain ; food, comfort, pain is the most important 
 of all the clinical matters concerned with the diagnosis of 
 gastric ulcer. 
 
 The next symptom in point of frequency is vomiting. 
 In all forms of ulceration of the stomach or duodenum 
 vomiting is an inconspicuous feature, unless obstruction 
 has developed as the result of the cicatrization of the 
 ulcer. Indeed, a degree of obstruction which is by no 
 means trivial may be present, and yet vomiting is very 
 infrequent or entirely absent. It is no uncommon experi- 
 ence to hear a patient say, "I never vomit," and for an 
 operation to disclose an extensive ulcer or a moderate 
 degree of stenosis in the body or near the pyloric orifice 
 of the stomach. Patients seem to have a great capacity 
 for estimating the degree of tolerance possessed by the 
 stomach, and of taking only such foods, or foods in such 
 measure, as will arouse no resentment. In the earlier 
 stages of the development of their malady vomiting is not 
 seldom self-induced in order to ease the stomach of a heavy 
 load, and a sense of pressure and distension. But a very 
 little experience seems to teach the greater number of
 
 74 ESSAYS ON SURGICAL SUBJECTS 
 
 patients the quantity of food that is appropriate for them. 
 Thereafter vomiting occurs quite infrequently. It has 
 probably been present on a few occasions in more than 
 half the number of patients who have suffered in many 
 attacks, but it is rare to find that quick reference is made 
 to it when the history is being disclosed. 
 
 When in the record of any patient suffering from 
 "dyspepsia" there is a story of frequent vomiting, of the 
 inability of the stomach to tolerate the presence of any 
 foods, of even fluid nourishment sparsely taken being at 
 once rejected, the thought that gastric ulcer is the cause 
 should be driven from one's mind. That type of history, 
 which is commonly heard, is, I find, rarely present in cases 
 of organic disease of the stomach. The vomiting due to 
 the presence of an ulcer is infrequent, and occurs almost 
 always not immediately after food, but after a shorter or 
 longer interval. The meal at first causes relief, and only 
 after that period of relief does it cause disturbance. 
 
 Hxmatemesis also occurs far less commonly than is 
 supposed. Haemorrhage manifest as melaena, or in the 
 vomit, is recorded in less than 25 per cent, of my cases; in 
 the majority of these the amount of blood lost was trivial, 
 and of many in which "haematemesis" is recorded it is at 
 least doubtful whether blood was, in truth, present I 
 think it is true to say that when blood is discharged from 
 the stomach either in a fresh state or as "black vomit," 
 it is commonly believed that a chronic ulcer is present. 
 There is a great fallacy in such opinions. That gastric 
 haemorrhage occurs, and occurs profusely, in ulceration 
 both of the stomach and duodenum is certain; but the 
 number of other conditions that give rise to haemorrhage 
 is so large that the possibility of a gastric ulcer being 
 the source of the blood should not be strongly, or ex-
 
 CHRONIC GASTRIC ULCER 75 
 
 clusively, held. I have so often seen haemorrhage of the 
 most abundant kind ascribed to "gastric ulcer" which 
 was caused by such other conditions as splenic anaemia, 
 cirrhosis of the liver, appendicitis, and other infective 
 conditions within the abdomen, that in the elucidation of 
 the cause of such a condition as profuse haematemesis I 
 seem to turn to other possibilities than gastric ulcer 
 in the first instance. It is true that there may be a 
 confusion as to terms here. For when a patient dies of 
 such haemorrhage a very close examination of the gastric 
 mucosa may reveal the existence of tiny chaps, or cracks, 
 or fissures from which blood has certainly issued. And 
 when in the old days of unwisdom we operated upon 
 such patients and explored the cavity of the stomach the 
 mucous membrane was said to "weep blood," little trickles 
 of blood could be seen to issue from many points. But 
 these little gaps in the mucosa are not ulcers of the kind 
 that produce clinical symptoms. If a patient has suffered 
 for months or years from dyspepsia, and then is seized with 
 an acute attack of vomiting and haematemesis, and if 
 an operation urgently performed reveals the condition 
 of the mucosa I have just described, it is the worst 
 of fallacies to connect the dyspepsia with the "ulcer" 
 or ulcers then supposed to be present in the stomach. 
 The ulcer which has caused repeated attacks of in- 
 digestion is always a gross lesion, a lesion in which there 
 are present not only the evidences of destruction, but 
 also of defence; around the crater of the ulcer is an 
 area, greater or less, of inflammatory action, and the 
 serous coat of the stomach is plainly involved. If the 
 breaches of continuity which permit the escape of blood in 
 cases of cirrhosis of the liver, splenic anaemia, and the 
 toxic conditions which, as a rule, have their origin within
 
 76 ESSAYS ON SURGICAL SUBJECTS 
 
 the abdomen, are called "acute ulcers," as they often are, 
 it is essential to remember that such ulcers are recognizable 
 by no other clinical evidence than haemorrhage, or in 
 exceedingly rare instances by perforation; they are never 
 the cause of a continuing or recent dyspepsia. The re- 
 lation between acute ulcers and the chronic ulcer which 
 is so disabling is not certain. Dr. Bolton, whose work on 
 Uker of the Stomach is the best of all books on its subject, 
 believes that one is a sequence of the other. He is prob- 
 ably right. Yet the acute ulcer as such gives no other 
 clinical indication of its existence than haemorrhage or per- 
 foration. The diagnosis of "gastric ulcer" in these cases 
 of grave haemorrhage was held to be confirmed by the 
 after-history and the results of medical treatment. The 
 patients regained health rapidly, soon lost their anaemia, 
 and were able to take food without restraint. But every- 
 one who has considered the history of cases in which there 
 has been a copious haemorrhage from the stomach will 
 agree that this rebound to full and vigourous health is quite 
 common. It is so even in cases in which at a later opera- 
 tion a frank gastric ulcer is seen. 
 
 Such, briefly stated, are the symptoms of gastric ulcer. 
 As will be realized, the chief dependence in making a 
 diagnosis is placed upon the one symptom pain. What 
 are the other methods of investigation which can help 
 us to a decision? Chief among them I now place the 
 examination of the stomach after a barium or bismuth 
 meal by x-rays. In this work I have relied upon my 
 colleague, Mr. Scargill, and I am greatly indebted to him 
 for his most careful and accurate work and for the skill 
 which he shows in the technical sides of it. His methods, 
 which follow closely upon those of R. D. Carman of the 
 Mayo Clinic, show that the possibility of making an
 
 CHRONIC GASTRIC ULCER 77 
 
 accurate diagnosis of gastric ulcer is greatly increased 
 by the x-ray examination; that, indeed, the radiographic 
 examination alone is more accurate than all other meth- 
 ods combined, and that a diagnosis which is proved 
 by subsequent operations to be correct in indicating the 
 presence of the ulcer or in demonstrating its size and 
 position can be made in about 90 per cent, of cases. 
 
 The following is his method of examination: After a 
 few hours of fasting, when the stomach is presumed to 
 be empty, a bismuth or barium meal of thin consistency 
 is given, and six hours later the first examination is made. 
 By this time a normal stomach is able to empty itself of 
 the small amount of opaque food administered. If a 
 residue is seen, there is a delay indicating defective 
 action. A second similar meal is now given and the 
 stomach examined forthwith. The radiographic signs of 
 gastric ulcer are*: 
 
 I. Direct. The ulcer cavity itself is demonstrated. If 
 an ulcer has penetrated into the walls of the stomach, or 
 eroded the liver or the pancreas, or perforated subacutely 
 and become adherent to the abdominal wall, the crater of 
 the ulcer can be seen filled with the opaque substance of a 
 meal. If the ulcer is near the lesser curvature, it is 
 visible in either an antero-posterior or semilateral view. 
 If the ulcer is on the posterior surface the best view is 
 obtained when the stomach is emptying. An ulcer on the 
 anterior or posterior surface of the stomach close to the 
 pylorus is more difficult to demonstrate. 
 
 II. Indirect. In the majority of cases of gastric 
 ulcer a very remarkable and sustained contraction of 
 the circular muscular fibres of the stomach occurs in 
 or near the segment on which the ulcer lies. An inden- 
 
 * For full details the work of Dr. Carman should be consulted.
 
 78 ESSAYS ON SURGICAL SUBJECTS 
 
 tation of the greater curvature, of varying degree and 
 extent, but often so considerable as to appear almost to 
 bisect the stomach, is most clearly seen. Its appearance, 
 whether on the screen or on a photographic plate, is re- 
 markable. The spasm, in the majority of cases, remains 
 stationary during the examination; it is unaltered by 
 palpation, massage, or by the administration of large 
 quantities of belladonna. It relaxes under a general 
 anaesthetic, and is not seen on the operation table, the 
 stomach wall being then quite soft and flaccid. A similar 
 "incisura" is present as the result of extrinsic causes- 
 causes lying, perhaps, remote from the stomach. The 
 commonest excitants are duodenal ulcer, infection of the 
 gall-bladder, with or without stones, and chronic appen- 
 dicitis. The spasm due to these causes is variable in posi- 
 tion and duration, is modified by massage or pressure, and 
 relaxes almost always after the administration of atropin 
 given in an amount which produces a physiological re- 
 sponse. It is also inconstant, present on one occasion, 
 absent on another, and changes capriciously. 
 
 The presence of the persistent spasm is strong pre- 
 sumptive evidence of the existence of an ulcer; the 
 presence of an "incisura" on the greater curvature, with 
 a "bud-like" opaque projection on the lesser curvature, 
 is an unequivocal evidence; in every such case an ulcer 
 is present. 
 
 The radiographic method is the one certain method 
 of diagnosis, and is now an indispensable addition to the 
 older and far less accurate procedures. 
 
 Of the chemical examination of the stomach contents 
 I do not speak with any enthusiasm. For several years 
 my patients were submitted to this form of investigation, 
 but I cannot think that the evidence thereby obtained
 
 Fig. 1. Very small "niche" type of ulcer on lesser curvature. Involves stomach 
 wall only. No incisuni seen in this case. \\ jpe marks costal margin. 
 
 Fig. 2. I leer crater on lesser curvature penetrating into loser omenlum. \\ ell- 
 marked incisura on the greater curvature, almost bisecting the stomach.
 
 Fig. 3. Ulcer crater on lesser curvature penetrating lesser omentum and ad- 
 herent to left lobe of liver. Well-marked incisura. 
 
 Fig. 4. Ulcer crater on lesser curvature. Incisura in this case is a little above 
 the level of the ulcer.
 
 ^^^^^^^HI^HHHnMHB 
 
 Fig. 5. Ulcer crater on posterior surface near lesser curvature, only seen when 
 stomach was almost empty. At operation found adherent to pancreas. 
 
 Fig. 6. Huge ulcer cavity on lesser curvature penetrating left lobe of liver. 
 The cavity was nearly 3^ inches long.
 
 Fig. 7. Groove-like ulcer on the lesser curvature 1^ inches long. Very well- 
 marked spasmodic hour-glass contraction. No hour-glass at operation. 
 
 Fig. 8. Ulcer crater on lesser curvature \\itli wril-markcd iucisura. (Dr. G. W. 
 
 Watson's case.)
 
 CHRONIC GASTRIC ULCER 79 
 
 enabled a greater accuracy to attach to the diagnosis or 
 justified the increased trouble it gave to them. Hyper- 
 chlorhydria is present in so many other diseases than 
 gastric or duodenal ulcer that its presence does not offer 
 positive or even contributory evidence of any real value. 
 In rather over 40 per cent, of the total number of cases in 
 which an ulcer is present there is no hyperchlorhydria, and 
 in a small number, estimated at from 10 to 20 per cent., 
 there is a reduction in the gastric acidity. For reasons 
 connected with the war I have rarely submitted patients 
 to this form of inquiry in the last four years, but it will be 
 interesting to discover the relationship, if any, between the 
 degree of gastric acidity and the quality and duration of 
 the gastric spasm due to extrinsic as well as intrinsic 
 causes. 
 
 Physical examination, in the absence of obstruction in 
 the body, or at the outlet of the stomach, reveals very 
 little. There is a record of tenderness in the epigastrium 
 in almost every one of the patients who are subsequently 
 found to have an ulcer in the stomach. In ulcers of the 
 lesser curvature I have sometimes found great tenderness 
 high up on the left along the costal margin tenderness 
 which becomes more acute when the patient breathes 
 deeply. The kind of sensitiveness is then present on the 
 left side which on the right establishes "Murphy's sign." 
 The signs in pyloric obstruction and in hour-glass stomach 
 are, of course, well known. 
 
 If all the methods of examination are strictly brought 
 to bear upon the cases commonly referred to as those of 
 "gastric ulcer" it will be found that in a majority the 
 diagnosis cannot be upheld. The diagnosis of gastric 
 ulcer is loosely and inaccurately made; a host of other 
 diseases, functional and organic alike, are so described,
 
 80 ESSAYS ON SURGICAL SUBJECTS 
 
 and in consequence the belief is widely held that "gastric 
 ulcer" is a common disease. It would be more accurate 
 to call it a rare disease. Over a series of years I find that 
 for every gastric ulcer seen on the operation table, there 
 are four or five duodenal ulcers, and five to six cases of 
 cholelithiasis. A gastric ulcer is by no means easy to 
 recognize even after the most scrupulous inquiry and ex- 
 amination. More mistakes are made in the diagnosis of 
 gastric ulcer than is the case in any other abdominal 
 disorder. 
 
 It must now be generally recognized that many of the 
 diseases arising in connexion with the abdominal viscera 
 are, for months or years, looked upon as cases of gastric 
 disorder. I pointed this out a few years ago in two papers 
 published in the BRITISH MEDICAL JOURNAL (October 
 18th, 1907, "Pathology of the living," and November 28th, 
 1908, "Inaugural Symptoms"). Up to the time of the 
 publication of these articles it had not been recognized 
 that in cholelithiasis, for example, all the prodromal symp- 
 toms were attributed to defects in the stomach, and the 
 medicaments administered were in consequence those used 
 in gastric diseases. The same statement holds good with 
 regard to chronic disease in the appendix, in the small 
 or in the large intestine. We are now familiar, as the 
 result of x-ray examination and of the chemical exami- 
 nation of the gastric contents, with the truth that all these 
 conditions express themselves in terms of gastric disturb- 
 ance, of hypersecretion, and of spasm. And at the time 
 when operations are performed we can discover by 
 inspection of the stomach such conditions as enable one 
 to predict that a lesion will be found on closer manual 
 examination not in the stomach, but in the appendix or its 
 neighbourhood.
 
 CHRONIC GASTRIC ULCER 81 
 
 If, for example, a patient has had a type of dyspepsia 
 which has led to a diagnosis of gastric ulcer and an opera- 
 tion is performed, the stomach may show no scar, nor can 
 any examination, however careful, display the ulcer whose 
 presence was predicted. If, however, the stomach is 
 closely inspected before it is handled the following con- 
 ditions may be seen: The pyloric part of the stomach is 
 decidedly redder than natural there is a "pyloric blush." 
 That part of the stomach is soon observed to contract 
 eagerly and vigorously ; sometimes the spasm is so severe 
 and so prolonged that there may be a suspicion of a tu- 
 mour, but by degrees the spasm relaxes, and the parts be- 
 come supple again. The spasm may be irregular, now at 
 one part, now at another; now slow and deliberate, now 
 fugitive. Along the greater curvature the glands are 
 enlarged. When these three conditions are seen the 
 prophecy may be confidently made that the stomach is 
 healthy and that the appendix (or one of its neighbours in 
 the alimentary canal) is diseased. In such cases gastro- 
 enterostomy has often been performed, sometimes, it is 
 curious to note, with benefit, but as a rule with disastrous 
 effects. It has been my lot to perform a secondary opera- 
 tion upon many such patients, and to remove a badly 
 diseased appendix or to resect a tuberculous intestine, and 
 perhaps to undo the anastomosis which should never 
 have been made. The work of Cole, Barclay, Carman, 
 and others explains quite clearly how it comes about that 
 these intestinal disorders affect the stomach and cause its 
 musculature to contract in the irregular and painful man- 
 ner which raises the suspicion, or seems to make certain 
 the opinion, that an ulcer is present. But there is also 
 the infective element in such cases, as Wilkie has shown 
 experimentally, and it is the toxaemia which is its outcome 
 
 6
 
 82 ESSAYS ON SURGICAL SUBJECTS 
 
 that leads, as Spencer and Hutchinson have shown, to 
 profuse haemorrhages from the stomach. 
 
 The stomach is an organ full of sympathy for other 
 sufferers. Hardly any of the viscera connected with the 
 intestine, or the bowel itself, can be affected without the 
 stomach playing its part in the disturbance also. This 
 it does by pouring out an excess of secretion, and by 
 tumultuous and irregular activities. It speaks so loudly 
 that its voice only is heard. 
 
 The whole subject now briefly mentioned requires close 
 and prolonged investigation. We must seek to find out 
 as accurately as possible the clinical indication that will 
 lead us to diagnose a veritable lesion of the stomach in 
 certain cases, and in others to be able confidently to say 
 that the stomach is intact, and that other organs are 
 telling the story of their own disease in terms of stomach 
 discomfort. 
 
 Differential Diagnosis 
 
 The very great difficulties in the diagnosis of gastric 
 ulcer are due to reasons which we can now fully appreciate. 
 An ulcer of the stomach does not arouse symptoms merely 
 because of the gap in one or more of the several layers of 
 the stomach. We may be certain of this because, after an 
 "attack" of gastric ulcer is over, and the patient is wholly 
 free from symptoms, an operation may disclose the open 
 crater of an ulcer large or small. The exact cause of the 
 symptoms is uncertain, but, so far as we know at present, 
 other conditions, in addition to the structural defect, must 
 be present before the symptoms appear. These are: 
 
 I. Evidences of infection around the ulcer, such as 
 induration, local peritonitis, the deposit of fat in and 
 around the base of the ulcer, and enlargement of neigh-
 
 CHRONIC GASTRIC ULCER 83 
 
 bouring glands. The "sentinel gland" of Lund is constant 
 in cases of active ulceration. 
 
 II. Spasm of the musculature of the stomach. Of the 
 presence, severity, and duration of this condition we had 
 very little knowledge until the methods of examination by 
 x-ray became perfected, chiefly by R. D. Carman. We 
 now know that a high degree of spasm is present and 
 constant in examples of ulcer of the stomach, and present, 
 though inconstant and variable, in those cases where there 
 is no primary lesion in the stomach. 
 
 III. An increase in the acidity of the gastric juice. 
 This hyperacidity is by no means constant either in 
 gastric or in duodenal ulcer, but it is possibly a factor of 
 importance in the awakening of symptoms. 
 
 These three conditions infection, localized spasm of 
 the gastric muscle, and hyperacidity are all present not 
 only in true ulcer of the stomach but also, in varying 
 degrees, in most of those distant conditions which are able 
 to arouse a gastric reflex; and it is their presence which 
 causes that mimicry of the symptoms of gastric ulcer by 
 other lesions which may be so exact as to deceive the 
 most expert enquirer. My own strong feeling is that in 
 order to obtain precision where so much has been vague, 
 no diagnosis of chronic ulcer should now be confidently 
 accepted unless the ulcer is diagnosed by x-ray examina- 
 tion or is displayed upon the operation table. 
 
 The diagnosis of gastric ulcer from a study of the 
 clinical and chemical evidences alone is so uncertain; the 
 various methods of treatment associated with the names 
 of Lenhartz, Leube, Cohnheim, Bolton, Sippy, and others, 
 so helpful in all cases of infection of the alimentary canal, 
 and the physical repose which accompanies the treatment 
 so weighty an influence for good, . that no certain con-
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 elusions can be drawn from even a long series of cases. 
 In order to allow of an accurate judgement to be made 
 of the value of any form of medical treatment we must 
 be certain, in the first place, that a real gastric ulcer is 
 present. The concurrence of the radiographer and the 
 surgeon in the diagnosis is necessary. The mere expres- 
 sion of an opinion, however confident, by a physician, 
 however distinguished, in the absence of this confirma- 
 tion, is for scientific purposes entirely without value. 
 When the diagnosis is assured and accepted, then med- 
 ical treatment may be carried out and its results exam- 
 ined. The radiographer should follow the treatment, 
 examining with the x-ray say once a month to discover 
 the changes which have taken place, and in the end to 
 assert that healing has, or has not, taken place. 
 
 The temporary absence of symptoms, as the surgeon 
 knows well enough, by no means indicates that the ulcer 
 is healed. If it is not healed the radiographer will recog- 
 nize the fact at once. There is urgent need of some 
 accurate knowledge upon these matters; at present we 
 have little or none. 
 
 How great the difficulty in diagnosis really is could 
 not be better shown than by a study of those cases in 
 which the patients have been given over to the care 
 of the surgeon for treatment, and in which the operation 
 of gastro-enterostomy has been performed without ben- 
 efit. There was a time when this operation was held 
 to be the certain cure for ulcer of the stomach. If its 
 "mechanical" virtues were not urgently needed because 
 of the obstruction caused by the ulcer, its "physiological" 
 effects at least would be salutary. A list of the diseases 
 called "gastric ulcer" by careful medical men, often 
 after consultation with others, and treated by operation,
 
 CHRONIC GASTRIC ULCER 85 
 
 was considered by me in a paper in the BRITISH MEDICAL 
 JOURNAL (July 12th, 1919). It is humiliating and heart- 
 breaking to ponder over the mistakes in diagnosis which 
 come to light in the records which were considered during 
 the preparation of that article. In many of these cases a 
 diagnoses of gastric ulcer had been made on evidence 
 that was considered adequate by careful practitioners. 
 We cannot rid the matter of error until we realize how 
 very difficult the diagnosis of gastric ulcer really is, and 
 until we decide that, no matter how confident the clinical 
 diagnosis may be before operation, it shall not guide 
 us during the operation too firmly. It is many years 
 since I decided for myself that no gastric or duodenal 
 ulcer existed unless it could be seen, felt, and demon- 
 strated to a sceptical onlooker. It will help to a better 
 understanding of the whole most difficult subject if in 
 future no diagnosis of gastric ulcer is accepted, as a 
 basis for treatment, unless the presence of the ulcer is 
 made certain by z-ray examination or by operation. To 
 accept the clinical diagnosis of gastric ulcer and to perform 
 any operation upon the stomach without most clearly 
 recognizing the ulcer is to court disaster. If the mistakes 
 in diagnosis to which I have referred had been followed 
 by medical rather than by surgical treatment, what would 
 be the value of the experience derived from the cases in 
 deciding upon the effect of similar treatment in veritable 
 cases of ulcer? The truth is that we cannot state in terms 
 of accuracy the results of medical treatment of gastric 
 ulcer unless and until we are certain that an ulcer has 
 been present. And, as I have said, the clinical evidences 
 alone are very fallacious.
 
 86 ESSAYS ON SURGICAL SUBJECTS 
 
 THE TREATMENT OF CHRONIC GASTRIC ULCER 
 A. Medical Treatment 
 
 I hope we may now agree that the results of the treat- 
 ment of gastric ulcer by any of the systems already 
 mentioned, or by any dietary or medicinal regimen, are 
 vitiated by the lack of accuracy in the diagnosis of gastric 
 ulcer. The most popular of all methods is that introduced 
 by Sippy, which would appear to meet more combatantly 
 those conditions in the stomach which he believes must be 
 controlled before an ulcer can have the chance to heal. It 
 is based upon the wide-spread belief (is it anything more?) 
 that the reduction of the acid in the stomach is the first 
 necessity. This is attained by dilution of food, alkaliniza- 
 tion of the gastric contents every hour, by the adminis- 
 tration of fats, and by lavage. 
 
 The questions which in this connexion require answer 
 are: 
 
 1. Does a chronic gastric ulcer ever heal under 
 
 medical treatment? 
 
 2. Does it long remain healed? 
 
 3. Does it heal without producing such conditions as 
 
 need surgical treatment for their relief? 
 1. Chronic gastric ulcers probably heal sometimes 
 under treatment, or after the exercise of continued care 
 in diet. The scars left by their healing are seen, though 
 very rarely, in the post-mortem room and, still more in- 
 frequently, in the operation theatre. The discrepancy 
 between the reputed frequency of gastric ulcer and the 
 scarcity of the scars found in the dead-house has not 
 attracted adequate attention. The number of healed 
 cicatrices found in the operation theatre, when the stom- 
 ach is examined as a routine in almost all operations, is
 
 CHRONIC GASTRIC ULCER 87 
 
 exceedingly small. This may be due to the rarity with 
 which sound healing occurs, or to the tendency of healed 
 ulcers to break out afresh. All the available evidence 
 strongly supports the opinion that the firm healing of a 
 chronic gastric ulcer is a very unusual occurrence. 
 
 2. Do ulcers when healed long remain so? In the 
 majority of cases the answer must be No. The character- 
 istic quality in the symptoms of gastric ulcer is recurrence. 
 There is a succession of "attacks," of changing severity 
 and of variable length. The tendency, on the whole, is 
 towards more serious attacks with briefer intervals. It is 
 not by any means certain that an interval in which there 
 is freedom from suffering means that the ulcer is healed. 
 In hour-glass stomach, where a considerable degree 
 of contraction has occurred in the body of the organ, 
 it is a matter of great rarity to find that the ulcer is 
 soundly healed. 
 
 3. When a gastric ulcer of moderate or large size heals 
 there is inevitably some degree of contraction. In this 
 way hour-glass stomachs are produced, and stenosis near 
 the pylorus. We cannot say with what frequency the 
 successful medical treatment of a chronic gastric ulcer 
 produces the conditions which need surgical relief, but it 
 is certainly not seldom, for any large scar wherever 
 placed, and especially if it has contracted adhesions to 
 neighbouring parts, must embarrass the action of the 
 stomach, or cause distress after food. Notwithstanding 
 any or all of these considerations, a really serious attempt 
 to treat all cases of chronic gastric ulcer by medical treat- 
 ment should be made. It is best to have no half-measures. 
 It is at least arguable that the necessity for surgical relief 
 in many patients is due to a too perfunctory trial of 
 medical treatment in the earlier attacks. The hospitaj
 
 88 ESSAYS ON SURGICAL SUBJECTS 
 
 accommodation in the country is too small to allow of the 
 poorer classes receiving the rest and supervision that is 
 necessary. The pressure on beds is too heavy. The ideal 
 would be to keep the patient under treatment until an 
 x-ray examination showed that the ulcer was healed. 
 
 B. Surgical Treatment 
 
 In discussing the surgical treatment of gastric ulcer the 
 first matter for consideration relates to the importance 
 of discovering any sources of still continuing infection 
 which may first have led to the development of the ulcer. 
 The primary infection cannot always be discovered 
 indeed, cannot often be localized with certainty but it is 
 a fair assumption to make that any chronic infection of 
 which the evidences are still discoverable may have acted 
 as a cause of the original ulcer, or have provoked a re- 
 currence of it in one or more of those attacks which are a 
 characteristic feature of the clinical history. The causal 
 infection may not be found until the abdomen is opened, 
 for in my view a large number of the cases of gastric ulcer 
 upon which the surgeon must operate are secondary to 
 an infection arising in some part of the intestinal canal, 
 more especially in the appendix. But there are not a 
 few cases in which the infective agent appears to reach 
 the stomach by way of the mouth. Disease of the 
 teeth or gums, of the antrum or other accessory sinuses, 
 or of the nasopharynx, have all been found in cases upon 
 which I was asked to operate. If in any such case the 
 lesion is a gross one, and likely long to continue, it is most 
 necessary that it should be dealt with before any operation 
 upon the ulcer itself is undertaken. If constant search is 
 made for a diseased fang, alveolar abscesses, and septic 
 conditions in the upper part of the pharynx or air passages,
 
 CHRONIC GASTRIC ULCER 89 
 
 the evidence of serious disease, requiring radical treat- 
 ment, will be discovered far more frequently than is 
 generally believed. One method of inquiry worth pur- 
 suing is the investigation by x-ray of the alveolar proc- 
 esses in all patients to whom a barium meal is to be 
 given preparatory to a screen examination of the stomach. 
 One of the factors most certainly causing a recurrence of 
 ulceration in the stomach, or of ulceration at or near the 
 suture line after gastro-enterostomy has been performed, 
 is infection derived from one or other of the several sources 
 here indicated. 
 
 The necessity for the surgical treatment of a gastric 
 ulcer is a confession that medical treatment has failed. 
 As commonly employed, it is doomed to failure. It too 
 often consists in the mere administration of a bismuth 
 mixture when the sufferer is treated in the out-patient 
 department of a large hospital. There is not anything 
 approaching the necessary accommodation in hospitals in 
 this country for the patients suffering from gastric or 
 duodenal ulcers, whose successful treatment by medical 
 means necessitates that constant, watchful supervision 
 of every detail which hospital treatment alone affords. 
 A successful operation upon a patient suffering from 
 gastric or duodenal ulceration will depend in part upon 
 careful and adequate preparation. Not a few of the 
 patients are weakly, ill-nourished, and of a low resisting 
 power when first they come under our care. By keeping 
 them at rest for a few days, giving them large quantities 
 of fluid by the mouth, or by rectum, or subcutaneously; 
 by the administration in such fluid of sodium carbonate 
 or glucose; or occasionally by performing a direct trans- 
 fusion of blood, their condition can be greatly benefited, 
 and the risks of operation correspondingly reduced. The
 
 90 ESSAYS ON SURGICAL SUBJECTS 
 
 practise of withholding fluids for a few hours before 
 operation is always, I think, a procedure of very question- 
 able value; in patients reduced in strength by lack of 
 nourishment, or by pain extending over long periods, it is 
 positively a factor pregnant with harm. When the opera- 
 tion is performed the choice in exceptional circumstances 
 of hedonal as an anesthetic is very helpful. The anaes- 
 thesia is quietly induced, lasts long, gives remarkable 
 relaxation of the abdominal wall, and provides two or 
 three pints of fluid at a time when fluid is much needed. 
 The surgical treatment of a chronic gastric ulcer* may 
 call for the performance of one or other of the following 
 operations: 
 
 I. Gastro-enterostomy. 
 II. Excision. 
 
 III. Gastro-enterostomy combined with excision by knife or by cautery 
 
 (Balfour's operation). 
 
 IV. Gastro-enterostomy combined with jejunostomy (Moynihan). 
 
 V. Resection of a part of the body of the stomach "sleeve resection." 
 VI. Partial gastrectomy. 
 
 I. GASTRO-ENTEROSTOMY 
 
 The operation which has been the most frequently 
 practised in the past, and is still that preferred by many 
 operators, is gastro-enterostomy. The operation was first 
 practised on September 27th, 1881, by Wolfler in Vienna. 
 He was dealing with a case in which carcinoma of the 
 pyloric part of the stomach was causing obstruction, and 
 the intention was to remove the growth by one of the 
 methods recently introduced by his master, Billroth. 
 Owing to the presence of secondary deposits and the 
 fixity of the tumour, resection was impossible, and the 
 abdomen was about to be closed when Nicoladoni, acting 
 
 * Discussion of the treatment of the acute perforation of a chronic gastric 
 ulcer is omitted from this paper.
 
 CHRONIC GASTRIC ULCER 91 
 
 as assistant, suggested that the obstruction might be 
 relieved by making an opening between the stomach and 
 the small intestine. The success in this, and in many 
 similar cases, was an event of great significance, and one 
 of the most important landmarks in the history of ab- 
 dominal surgery. It was not long before examples of 
 pyloric stenosis due to the healing of a simple ulcer were 
 treated by the same method. What happened is known 
 to all the world. Patients who had suffered for years from 
 the miseries of the confirmed dyspeptic, who finally had 
 the extreme discomforts caused by the recurrent vomiting 
 of the stagnant and fermenting contents of the stomach, 
 who lived on the most restricted diet in order that their 
 sufferings might be lessened, were suddenly restored to 
 vigourous health, were able to satisfy, without appre- 
 hension or unhappy consequences, their keen appetites; 
 rapidly gained health and happiness, and added con- 
 siderably to their weight. No operation in surgery had 
 ever produced more striking or swifter results. Owing 
 largely to the advocacy and the successful work of Doyen, 
 the operation began to be practised in cases of ulcer oc- 
 curring in the body of the stomach, cases in which no 
 obstruction was caused either by the open ulcer or by the 
 stenosis resulting from its partial cicatrization. 
 
 Results by no means so happy were soon witnessed, and 
 in cases whose number seemed quickly to mount up the 
 ultimate consequences of the operation were disastrous. 
 There were several reasons for this. The chief, perhaps, 
 was the inaccuracy of the diagnosis in many instances. 
 It was not then, it is not now, sufficiently realized that the 
 diagnosis of gastric ulcer is difficult and that the disease 
 is rare. The operation came to be practised for "chronic 
 dyspepsia," and many of the little splashes of thick lymph
 
 92 ESSAYS ON SURGICAL SUBJECTS 
 
 so often seen on the under surface of the transverse meso- 
 colon, adherent to the posterior wall of the stomach, were 
 assumed to be the scars of gastric ulcers which had healed. 
 And so in many cases when the stomach was normal, 
 where the lesion causing the symptoms lay elsewhere, the 
 short-circuiting operation was performed, with unhappy 
 consequences. Another reason for the disasters following 
 upon operation was a technical one. The anastomosis 
 was made with a long proximal loop, which, emptying with 
 increasing difficulty, became waterlogged; or adhesions 
 obstructed the efferent jejunum; or the opening into the 
 stomach was badly placed. From one or other cause 
 such difficulties as regurgitant vomiting were frequently 
 seen. Further reasons were found in the inability of the 
 ulcer to heal even after gastro-enterostomy had been per- 
 fectly performed in an appropriate case, and in the later 
 development of cancer of the stomach, presumably upon 
 the base of an unclosed ulcer. 
 
 A few years ago a revision of my own cases in which 
 a gastric ulcer had been clearly demonstrated showed that 
 the results could be classified into three groups. 
 
 1. The Results were Excellent. With the same alacrity 
 that is witnessed in cases of duodenal ulcer, or in cases of 
 pyloric stenosis, the patient lost all discomforts, and made 
 a speedy and excellent return to health. I had not then 
 in all cases indicated in a diagram, made immediately after 
 the operation as I do now, the exact position and the 
 approximate size of the ulcer; and therefore I am not able 
 , to say exactly what the condition of the stomach was in 
 this group of cases. But in many cases it is certain that 
 the ulcer was near the pylorus; that the gastro-enteros- 
 tomy opening was on the proximal side of it. In others 
 the ulcer was on the lesser curvature and was small,
 
 CHRONIC GASTRIC ULCER 93 
 
 and free from adhesions. It had not, that is to say, 
 perforated the coats of the stomach to become adherent to 
 the abdominal wall, liver, or pancreas. 
 
 2. The Results were Indifferent. Some patients were 
 found to have improved, in many cases for periods of 
 months or years, others were known to have relapsed. At 
 a subsequent operation the ulcer was found to be still 
 present; it was then removed by local excision by the 
 cautery, or by the performance of the operation of partial 
 gastrectomy. 
 
 3. The Results were Bad. In this class of cases 
 malignant disease developed in the base of the ulcer, 
 and so near the ulcer as to make differentiation im- 
 possible. The question of the degeneracy of a simple 
 ulcer into a malignant one is still warmly debated, and 
 there is no approach to an agreement between the several 
 authorities. The evidence considered by the protagonists 
 on either side is clinical and pathological. 
 
 In more than half the cases of carcinoma of the stomach 
 treated by operation there is a history suggestive of the 
 previous existence and of the recurrence of a gastric ulcer. 
 No one is more ready than I am to admit that such a 
 history is not a full warrant for asserting that an ulcer 
 has been present. For on the clinical evidences alone 
 a diagnosis of gastric ulcer, however confidently made, 
 cannot always be upheld. The only certain evidence 
 obtained before operation is afforded by a radiological 
 examination, and I do not know of any case in which 
 a diagnosis of gastric ulcer has been positively made with 
 this and other methods in which carcinoma was subse- 
 quently found. The clinical evidences, therefore, how- 
 ever strongly suggestive, are not positive proof. In about 
 25 to 30 per cent, of the cases of carcinoma of the stomach
 
 9U ESSAYS ON SURGICAL SUBJECTS 
 
 removed by operation the claim that the malignant 
 change is imposed upon a simple one appears on patho- 
 logical grounds to be irrefutable; and every surgeon 
 knows that in a small number not less, certainly, than 
 10 per cent. of the cases of gastric ulcer, to all appear- 
 ances simple in character, a microscopic examination of 
 the specimen removed by operation reveals the early 
 stage of carcinoma. Now, histologists do not always 
 agree as to the conditions which may be accepted as 
 indicating the earliest changes from simple to carcino- 
 matous states. Much of our knowledge of the micro- 
 scopical appearances of cancer is based upon an examina- 
 tion of specimens long dead, of specimens months or 
 years old, which have been lying upon the laboratory 
 or museum shelves. The changes that occur in such 
 circumstances are not known. But, as I have ventured 
 to urge, an examination of specimens so recently removed 
 as to be hardly yet dead is necessary before we know 
 what conditions in carcinoma are authentic and what are 
 the changes which are merely due to corruption. We 
 must recognize a "histology of the living," which is 
 probably as far removed from the histology of the dead 
 as we now all recognize the "pathology of the living" 
 to be from the pathology of the dead. 
 
 We must finally consider this fact also, that when 
 gastro-enterostomy is performed for a chronic gastric 
 ulcer, the "physiological" results of the operation, though 
 they may not bring about the healing of the ulcer, may 
 yet delay or prevent its progress towards carcinoma. We 
 must take account of the possible effects produced by the 
 change from an acid to an alkaline medium. Nothing is 
 more remarkable than the difference in destiny of a 
 chronic duodenal ulcer and of a chronic gastric ulcer. It
 
 CHRONIC GASTRIC ULCER 95 
 
 is admittedly one of the great rarities in pathology to find 
 an ulcer of the duodenum that has become malignant; 
 and it is certainly a far more frequent thing, allowing for 
 all reservations, to find an ulcer of the stomach in which 
 carcinoma has developed. Embryologically the stomach 
 and the duodenum as far down as the ampulla of Vater are 
 one. This difference in the prospective changes in ulcers 
 on one or other side of the pylorus may be due to the 
 different reactions of the fluids by which they are bathed. 
 Those who practise the operation of gastro-enteros- 
 tomy for the relief of ulcers in the body of the stomach 
 rely upon the so-called "physiological results" of the opera- 
 tion that is, upon the effect produced by the constant 
 entry into the stomach through the anastomosis of the 
 alkaline bile and pancreatic juice. There is no doubt that 
 these juices are found in the contents of the stomach 
 removed by tubage in all cases after gastro-enterostomy 
 has been performed; and it is possible that the success of 
 the best methods of therapy in cases of gastric ulcer 
 that of Sippy, for example (in which, however, gastric 
 lavage is a factor of great value) -depends upon the 
 very frequent administration of alkalies, which, it is 
 claimed, neutralize the gastric acidity, and so allow of 
 healing in the ulcer. Much of the explanations given is 
 conjectural, and regard is perhaps insufficiently paid to 
 the effect of the administration of alkalies in provoking a 
 greater output of acid in the gastric juice to overcome the 
 alkali administered. I am very sceptical as to any sub- 
 stantial "physiological" value possessed by the opera- 
 tion of gastro-enterostomy. Its other effects are purely 
 mechanical. The stomach is emptied more quickly 
 through a gastro-enterostomy opening; the pyloric spasm 
 which so often accompanies gastric ulceration is robbed
 
 96 ESSAYS ON SURGICAL SUBJECTS 
 
 of its effects, and the persistent local spasm which causes 
 the characteristic "incisura" may either be prevented 
 by a division of the muscular fibres causing it or rendered 
 ineffective by the drainage of the stomach on its proximal 
 side. 
 
 The making of an anastomosis between the stomach 
 and the jejunum does not prevent the subsequent devel- 
 opment of a gastric ulcer. I have records of one case in 
 which a gastric ulcer, well removed from the anastomosis, 
 developed after the operation and went on to perforation; 
 and of three others in which gastric ulceration developed 
 after the performance of gastro-enterostomy for a duo- 
 denal ulcer. 
 
 Sherren 1 records a case of carcinoma of the stomach 
 developing in a patient upon whom gastro-enterostomy 
 was performed for a perforated duodenal ulcer. Coffey, 
 a surgeon of great sagacity, in a paper on "Gastro- 
 enterostomy Still the Operation for Chronic Gastric and 
 Duodenal Ulcer," records 2 two cases in which an ulcer in 
 the stomach developed after gastro-enterostomy had been 
 performed for duodenal ulcer. 
 
 In consequence of my experience I have abandoned 
 gastro-enterostomy alone in the treatment of chronic 
 gastric ulcer, for: 
 
 (a) The results, even when the operation was "suc- 
 cessful," were not so satisfactory as those which now 
 follow gastrectomy. The morbidity was greater, the re- 
 turn to health slower, the ability to take food early and 
 generously was wanting, a more watchful after-care was 
 necessary. 
 
 (6) Some cases returned with the ulcer still open, and a 
 further operation was required. In such cases the ulcer 
 had almost always perforated all the walls of the stomach,
 
 CHRONIC GASTRIC ULCER 97 
 
 and adhesions had occurred to the liver, pancreas, or 
 abdominal wall. 
 
 (c) Some few cases returned with carcinoma of the 
 stomach after so long an interval as to make it probable 
 that the cancerous change had occurred after the operation 
 had been performed. Estimates of this sort are, I admit, 
 fallacious, for the chronicity of some forms of malignant 
 disease of the stomach is remarkable. I have recently 
 been consulted, on account of a return of her symptoms, 
 by a patient upon whom four years and seven months ago 
 I performed gastro-enterostomy for carcinoma of the lesser 
 curvature of the stomach, causing obstruction, when 
 secondary deposits were present in many glands, in the 
 falciform ligament (one of these nodules was removed for 
 microscopical examination and confirmed the diagnosis), 
 and the liver. 
 
 (d) There is evidence to show that gastric ulcer may 
 develop, even after gastro-enterostomy has been per- 
 formed, when the stomach itself was normal. 
 
 The operation of gastro-enterostomy is made as simple 
 as possible, though it is by no means always easy. Clamps 
 are used, and vertical application of the highest ac- 
 cessible portion of the jejunum is made to the posterior 
 surface of the stomach along a line which is a continua- 
 tion downwards of the upper part of the lesser curvature. 
 In this way the lowest portion of the stomach is drained 
 by the new opening. Two layers of sutures are used ; both 
 are of the finest chromic catgut (six nought). It is never 
 necessary to have more than two layers, nor to use any 
 unabsorbable material, such as linen or thread or coarse 
 chromic catgut. Any large vessel springing from the 
 greater curvature and running directly on to the anasto- 
 motic line is ligatured separately. The opening into the 
 
 7
 
 98 ESSAYS ON SURGICAL SUBJECTS 
 
 lesser sac is carefully closed by approximating the cut 
 edges of the transverse mesocolon to the suture line. The 
 principles applicable in all operations are observed gentle 
 handling, absence of exposure or chilling of any parts 
 directly engaged in the operation, and scrupulous care at 
 every step. The mortality in my own hands during the 
 last ten years is 1 per cent., and there has been no death 
 in the last 350 cases of gastric or duodenal ulcer. 
 
 II. EXCISION 
 
 The operation of excision was introduced with great 
 hopes, which, unhappily, have not been gratified. I have 
 practised excision by several routes, and have removed 
 ulcers of various sizes. A small ulcer on the anterior or 
 posterior surface has been excised, and the opening left in 
 the stomach either closed by interrupted sutures of catgut 
 or utilized to form an anastomosis with the jejunum. 
 Wedge-shaped excision of ulcers on the lesser curvature 
 has been carried out, sometimes with ease, oftener with 
 difficulty, and with a resulting deformity of the stomach. 
 Ulcers on the posterior wall, perhaps burrowing into the 
 pancreas, have also been removed through an incision in 
 the anterior wall of the stomach. I have been profoundly 
 disappointed with the results. My colleague, Mr. Collin- 
 son, in a paper read before the American Medical Asso- 
 ciation in 1914, 3 found that in thirty-nine cases of excision 
 there were fifteen in which severe recurrence of symptoms 
 was observed. Eleven patients were submitted to a 
 second operation, and seven of them showed active 
 ulceration at the site of the excision, one had developed 
 a fresh ulcer distal to the original one, and three had 
 extensive adhesions which crippled the action of the 
 stomach. The operation may fail on account of technical
 
 CHRONIC GASTRIC ULCER 99 
 
 errors. Too small an area of induration surrounding the 
 actual crater may be removed; the hard, stiffened edges 
 of the wound which remain, infiltrated by inflammatory 
 products which have long been there, may not heal 
 kindly or rapidly, and fresh ulceration may start be- 
 fore cicatrization is complete. Of such a condition I 
 found evidence in a case of my own, related by Mr. 
 Collinson in the paper to which I have referred. In 
 other cases a deformity of the stomach may be consequent 
 upon the removal of an ulcer, especially of one which lay 
 upon, or near, the lesser curvature; the normal peristaltic 
 movements will then be checked at the line of scar, as a 
 radiological examination will plainly declare. The use of 
 unabsorbable sutures, especially continuous sutures, may 
 lead to secondary ulceration. All continuous "sero- 
 muscular" sutures probably penetrate to the mucosa in 
 more places than one ; if this occurs, the suture will even- 
 tually ulcerate its way through to the lumen of the bowel 
 and be discharged, or hang loose at the suture line for 
 months or years. Finally, even with a careful technique, 
 adhesions may form between the suture line and any 
 viscus or the abdominal wall in contact with it, and some 
 embarrassment of the action of the stomach will then 
 certainly result. 
 
 For these reasons, and in spite of some very satisfactory 
 results, I have abandoned the operation altogether in 
 cases of gastric ulcer. The disappointments it brings are 
 too many, and are neither easy to foresee nor certainly to 
 be prevented.
 
 100 ESSAYS ON SURGICAL SUBJECTS 
 
 III. EXCISION, BY KNIFE OR BY CAUTERY, COMBINED WITH 
 GASTRO-ENTEROSTOMY 
 
 At an early stage in our experience of the operation of 
 excision alone it was found that in some instances, after 
 suture of the wound was complete, a considerable degree 
 of distortion of the stomach resulted, the lesser curvature 
 was much puckered, and the whole organ warped in out- 
 line. To have left the stomach in such a condition would 
 inevitably have meant that a further operation would soon 
 be necessary in order to overcome mechanical difficulties. 
 And little by little it became the practice to combine with 
 the operation of excision that of gastro-enterostomy also. 
 The results were certainly better than before, but the 
 combined operations, in point of difficulty always, and 
 often in point of time and of danger also, equalled or ex- 
 ceeded the operation of partial gastrectomy. As the 
 technique of this latter operation was steadily improved, it 
 began in my own hands to replace other methods, and I 
 reverted to the practice so ably advocated by Rodman, 
 of "removal of the ulcer-bearing area." 
 
 Balfour of Rochester, with that fertility of resource 
 which is one of the characteristics of his fine work, re- 
 placed the method of excision of the ulcer by that of its 
 complete destruction by the actual cautery. Balfour's 
 operation has among its many merits that of simplicity. 
 If an ulcer lie upon the lesser curvature, or near it, a 
 little nearer the cardia than the pylorus, or down upon the 
 posterior wall, the operation of excision was apt to be 
 difficult. The method of Balfour makes the treatment 
 very much easier, quicker, safer, and gives results far 
 more satisfactory. I learnt the method in Rochester, 
 where I saw several operations performed by W. J. Mayo.
 
 CHRONIC GASTRIC ULCER 101 
 
 In ulcers near or upon the lesser curvature there is often 
 a covering of fat, developed probably, as in the case of an 
 infected gall-bladder, as a protection against perforation. 
 This fat is dissected upwards towards the lesser curvature, 
 until the base of the ulcer is seen clearly. The crater of 
 the ulcer is then completely destroyed by the actual 
 cautery, which pierces the entire thickness of the wall of 
 the stomach. The gap which remains is closed by in- 
 terrupted sutures, in two layers, and the flap of fat turned 
 downwards to cover the suture line like a lid. Posterior 
 gastro-enterostomy is then performed in the usual manner. 
 
 Of all methods of dealing with gastric ulcer, short of 
 gastrectomy, I am convinced that this is one of the best; 
 it destroys the ulcer more completely than does the method 
 of excision, for the effect of the cautery extends widely 
 beyond the seared edge of the wound. If by chance there 
 is an early carcinomatous change, it is probable that much 
 of the risk of local recurrence is removed. No more tissue 
 is sacrificed than is necessary, and the suture of the wound 
 offers, as a rule, no difficulty. 
 
 My own experience of this operation is small. At the 
 time when I should have been inclined to make it an 
 almost routine procedure for many cases I had been led by 
 my unsatisfying experience of other methods to become 
 more and more radical in the treatment of gastric ulcer, 
 and to consider the removal of the part of the stomach as 
 the operation of choice. There are, however, cases in 
 which everyone will admit the great value of the operation : 
 cases of ulcers difficult of access, in patients for whom, 
 because of recent haemorrhages, or a degree of pain which 
 has made the taking of food exceedingly difficult, the 
 simplest operation that is sufficient to cure, or relieve the 
 disease, is indicated.
 
 102 ESSAYS ON SURGICAL SUBJECTS 
 
 IV. GASTRO-ENTEROSTOMY COMBINED WITH JEJUNOSTOMY 
 
 This is a method which I have advocated and practised 
 in cases of grave difficulty. The results have been ex- 
 cellent. There are ulcers of the stomach so large, so 
 awkwardly placed, and so deeply penetrating the liver, 
 or the pancreas, in patients whose general condition is so 
 poor that any operation becomes serious. Such cases may 
 be unsuitable for Balfour's operation, by reason of the size 
 or remoteness of the ulcer; and for the operation of 
 gastrectomy by reason of the extremely feeble condition 
 of the patient, who has perhaps recently suffered from a 
 copious haemorrhage. In all such cases I perform gastro- 
 enterostomy in "Y," generally by the anterior route. The 
 intestine is cut across about 18 in. below the flexure, the 
 distal end closed, and the side of this distal part united 
 to the anterior wall of the stomach. As large an opening 
 as possible is made proximal to, or in the zone of, the ulcer 
 and extending sometimes over the fundus of the stomach. 
 The proximal divided end of the jejunum is then anas- 
 tomosed to the side of the distal limb a few inches below 
 the gastro-enterostomy opening. Into this proximal part, 
 at a point about 3 in. above the junction which has just 
 been made with the distal limb, a tube is introduced and 
 fixed by the method of Witzel. The tube passes for 
 several inches down through the entero-anastomosis 
 into the jejunum. It is brought out of the abdominal 
 wall through a small separate incision to the left of 
 the umbilicus. It is through this tube that all nourish- 
 ment is given for months, or for years, until a radiological 
 examination shows that the ulcer is healed, or until a 
 trial of one month, during which food is given, discloses 
 no return of the symptoms. During this time the
 
 CHRONIC GASTRIC ULCER 103 
 
 greatest care is taken to keep the mouth clean by friction 
 and frequent washing. I have never had any difficulty 
 with a patient craving for food. The sufferings endured 
 before operation, and the relief immediately afterwards, 
 by their sharp contrast, make the patient disposed to do 
 all one asks. One patient, whose stomach showed the 
 largest ulcer I have ever seen (we described it as resembling 
 the mouth of a letter box through which the hand passed 
 deeply into the liver), took no food for two years and nine 
 months after this operation, though I gave her permission 
 to do so. She took food generously through the tube, 
 and gained over 50 pounds in weight. Since removing 
 the tube, now a few years ago, there has been no recur- 
 rence of symptoms. Indeed, up to the present time, in 
 no case in which this operation has been practised has 
 the ulcer returned. 
 
 V. RESECTION OF A PART OF THE BODY OF THE STOMACH 
 -"SLEEVE RESECTION" 
 
 This operation is, of course, reserved for those cases in 
 which the ulcer occupies approximately the middle part of 
 the stomach. After resection of a cylindrical portion of 
 the organ the cut ends are united. Advocacy of this 
 operation appears to be restricted to a few surgeons, and 
 consequently the number of cases performed is relatively 
 small. I practised it on two occasions only, long ago. In 
 both the operation promised well, but one of the patients 
 returned after four years with an hour-glass stomach, for 
 which a second operation was necessary. The role of the 
 operation is necessarily a very limited one. I think I am 
 hardly likely to perform it again. But so far as I can 
 judge of the experience of others it has had a fair measure 
 of success.
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 VI. PARTIAL GASTRECTOMY 
 
 My early experience of the operations already men- 
 tioned was satisfactory enough so far as immediate results 
 were concerned; but as time passed patients began to re- 
 turn with one degree of discomfort or another, until I was 
 convinced that many of the methods practised were not 
 justified by their end-results. And by degrees I was 
 brought to realize that gastric ulcer was a far more serious 
 disease than duodenal ulcer. It was soon found to be 
 comparatively a rare disease, far less frequent in occur- 
 rence than had been universally believed, and certainly 
 very difficult indeed to diagnose with confident assurance 
 and constant accuracy. The diagnosis so frequently made 
 of "gastric ulcer" in out-patient rooms and in private 
 practice is not sustained when the parts are examined 
 upon the operation table. Other diseases duodenal 
 ulcer, chronic appendicitis, cholelithiasis, tuberculous 
 enteritis, laxity of the attachments of the colon are all 
 found in the absence of any palpable or visible lesion of 
 the stomach, and explain the symptoms of which the 
 patient has complained. A host of diseases, organic and 
 functional alike, are called "gastric ulcer." And conse- 
 quently much of the literature and most of the statistics 
 dealing with the subject of "gastric ulcer" lack that 
 foundation of truth which only an accurate diagnosis can 
 afford. 
 
 In the cases of indisputable gastric ulcer, when the 
 ulcer is demonstrated beyond cavil by a radiological 
 examination or by inspection upon the operation table, 
 a far greater seriousness attaches to the disease than to 
 the condition of duodenal ulcer. Operations upon it are 
 more serious, partly by reason of the extent of the opera-
 
 CHRONIC GASTRIC ULCER 105 
 
 tions themselves, chiefly, I think, in consequence of the 
 less robust state of the patients. Recoveries after 
 operation are fewer whatever the nature of the opera- 
 tion, and the rate of mortality of the patients in the years 
 subsequent to operation, as Balfour has recently shown 
 in a paper of great value and of new significance, 4 is, 
 in the cases attended in the Mayo Clinic, three times as 
 high as in patients operated upon for duodenal ulcer. 
 This, on reflection, is not so startling a fact as may at 
 first appear; for many of the patients suffering from 
 duodenal ulcer are men otherwise of robust strength and 
 splendid health. I have operated upon international 
 football players, golfers, lacrosse players, and many dis- 
 tinguished athletes for duodenal ulcer. Such people are 
 not often found among those who suffer from gastric 
 ulcer; and, though there are exceptions, the types of 
 stomach found in the two diseases are distinct from one 
 another, as Hurst has shown. The local conditions found 
 in the two diseases are different also. A duodenal ulcer 
 is often a simple round "terraced" ulcer affecting the 
 intestine alone; a gastric ulcer is very prone to extend 
 and to burrow deeply into other parts the pancreas, the 
 liver, the abdominal wall; and the later history of the two 
 diseases is very different. I lean to the belief that many 
 of the cases of carcinoma of the stomach with which 
 the surgeon can deal successfully have their origin in a 
 chronic ulcer. That is not the universal view, but the 
 opinion of those who hold it is weighty and well founded. 
 Carcinoma is excessively rare in that part of the duo- 
 denum affected by chronic ulcer. Prompted by all these 
 considerations, I was gradually brought to view gastric 
 ulcer as a disease requiring direct and radical treatment, 
 and that it was not safe to trust to the indirect method
 
 106 ESSAYS ON SURGICAL SUBJECTS 
 
 of gastro-enterostomy, which, whether its action is 
 "physiological" or mechanical, merely produces a con- 
 dition of things in which healing can more easily take 
 place. 
 
 My choice of operation now always falls upon partial 
 gastrectomy, whenever it can with reasonable safety be 
 performed. The risk is not great: over a period of ten 
 years it is not more than 2.5 per cent. All things con- 
 sidered, and account being taken of the five years suc- 
 ceeding operation, it is probably a safer operation and 
 is certainly more immediately satisfactory than gastro- 
 enterostomy alone. It cannot always be practised. The 
 condition of the patient may forbid it. The ulcer may be 
 so large and so placed as to make removal a matter of so 
 great technical difficulty that the immediate hazards are 
 unfair to the patient. But as experience grows the 
 number of such cases diminishes. Nowadays I rarely 
 practise any other operation than partial gastrectomy or 
 gastro-enterostomy in "Y" combined with jejunostomy. 
 The details of the operation of gastrectomy are briefly 
 these: The duodenum is divided just beyond the pylorus, 
 after ligature of the pyloric and gastro-duodenal arteries. 
 An opening is made in the transverse mesocolon, in the 
 arch of the anastomosis of Riolan in order to guide the 
 surgeon in his ligature of the omentum below the greater 
 curvature, so that the middle colic artery may be avoided, 
 and in order that the conditions at the back of the stomach 
 may be early and fully investigated. After division of 
 the great omentum as far towards the left as the point 
 at which the stomach is to be divided, the whole organ is 
 turned over the left edge of the parietal wound, until the 
 coronary artery is brought into view and ligatured with 
 great ease at exactly the place required. As soon as this
 
 CHRONIC GASTRIC ULCER 107 
 
 vessel is cut an anchor is "let go," and the stomach is 
 moved more freely. Then while the stomach is held as a 
 retractor an anastomosis is made between it and the 
 jejunum. I now always apply the end of the stomach to 
 the side of the jejunum. 
 
 In my early cases I twice encountered a little diffi- 
 culty in making the jejunum so apply itself to the stomach 
 as to avoid a kink at the upper end of the anastomosis. 
 In both cases some bilious vomiting occurred. In order 
 to prevent this I now usually divide the jejunum com- 
 pletely across, about eight to ten inches below the duo- 
 deno-jejunal flexure, close the distal end, and make an 
 anastomosis in "Y." This takes a few minutes longer, 
 but the expenditure of time is worth while. The results 
 are excellent. The condition after operation is remark- 
 ably good; in almost all cases the patients have the most 
 tranquil progress that one could wish. And not one sin- 
 gle case I have ever operated upon has had a recurrence 
 of trouble. Once the convalescence is complete the his- 
 tory is without incident. 
 
 Whatever the operation from among all those men- 
 tioned which may be selected in each individual case 
 regard must always be paid to the power of the patient to 
 bear it, and to its exact application to the particular 
 conditions disclosed when the parts are directly examined. 
 Before the operation commences the surgeon should never 
 reach a definite decision to perform any one procedure; he 
 must apply at the moment of operation the method which 
 best meets the indications in each case. And here, as 
 elsewhere, the little things count. Care in preparation, 
 scrupulous exactitude in every detail, gentleness, delibera- 
 tion, with such speed as comes naturally from much 
 practice, and is unsought as a special feature all these
 
 108 
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 together will sometimes turn what would otherwise be 
 failure into easy and certain success. 
 
 Statistics 
 
 For the purpose of illustrating my practice in con- 
 nexion with operations upon the stomach and duodenum I 
 have collected together, with the help of my colleague, Mr. 
 E. R. Flint, and my secretary, Miss Mackill, all the records 
 of cases operated upon by myself since the year 1909, in- 
 cluding the very lean years of war. Every case of simple 
 disease of the stomach or duodenum (excepting acute per- 
 foration) is included: cases of gastric ulcer, hour-glass 
 stomach, duodenal ulcer, and jejunal or gastro-jejunal 
 ulcer following upon gastro-enterostomy. 
 
 The cases of ulceration* are as follows: 
 
 Ulceration 
 
 
 Cases. 
 
 Deaths. 
 
 Gastric ulcer alone 
 
 196] 
 
 
 Gastric ulcer with duodenal ulcer (including some cases 
 of hour-glass stomach) 
 
 37 256 
 
 7 = 2.7% 
 
 Gastric ulcer alone causing hour-glass stomach 
 
 231 
 
 
 Duodenal ulcer alone 
 
 605 
 
 3 = 0.49% 
 
 Pyloric ulcer 
 
 9 
 
 o 
 
 Jejunal or gastro-jejunal ulcer 
 
 33 
 
 2 = 6.0% 
 
 
 
 
 The greater severity of cases of gastric ulcer as com- 
 pared with duodenal ulcer is strikingly shown; and the 
 serious nature of cases of jejunal ulcer is evident. 
 
 * The figures in these tables have been brought up to December, 1920.
 
 CHRONIC GASTRIC ULCER 
 
 109 
 
 Operations Performed 
 
 Operation. 
 
 Cases. 
 
 Deaths. 
 
 Remarks. 
 
 Gastrectomy 
 
 100 
 
 2 = 2.0% 
 
 3ne case of almost total 
 
 
 
 
 gastrectomy for large mul- 
 
 
 
 
 tiple ulcers, eroding the 
 
 
 
 
 pancreas and the liver. 
 
 Gastro-enterostomy 
 
 ) 
 
 
 
 Posterior 
 
 
 ft ff 
 
 Five deaths were due to lung 
 
 Anterior 
 
 
 v * i/c 
 
 complications, associated 
 
 In "Y" 
 
 \ 738 
 
 l =\/ 
 
 
 in one with tuberculosis. 
 
 In "Y" with jejunostomy 
 
 
 
 
 With gastrostomy 
 
 
 
 
 (All these combined in a 
 
 / 
 
 
 
 great majority of cases 
 
 
 
 
 with removal of the ap- 
 
 
 
 
 pendix, and several with 
 
 
 
 
 operations upon the gall- 
 
 
 
 
 bladder. In two ovariot- 
 
 
 
 
 omy was performed also.) 
 
 
 
 
 Excision of gastric or duo- 
 
 4 
 
 1 
 
 The fatal case was one of 
 
 denal ulcer with or with- 
 
 
 
 duodenal ulcer; cholecys- 
 
 out gastro-enterostomy, 
 
 
 
 tectomy and appendicec- 
 
 including Balfour's opera- 
 
 
 
 tomy were also performed. 
 
 tion. 
 
 
 
 
 Hour-glass stomach (mul- 
 
 19 
 
 1 
 
 Post-mortem report: "Ex- 
 
 tiple operations, gastro- 
 
 
 
 treme fatty infiltration of 
 
 enterostomy with gastro- 
 
 
 
 right auricle and ventricle, 
 
 gastrostomy, etc.). 
 
 
 
 chronic fibrosis of kid- 
 
 
 
 
 neys." 
 
 Jejunostomy 
 
 4 
 
 1 
 
 The fatal case had a gastro- 
 
 
 
 
 jejunal ulcer of large size, 
 
 
 
 
 with much induration 
 
 
 
 
 around it. The patient 
 
 
 
 
 was exceedingly ill, and 
 
 
 
 
 suffering intense pain. 
 
 Summary 
 
 There were in all 905 operations, with 12 deaths a 
 total mortality of 1.32 per cent. Excluding the cases 
 of jejunal ulcer there were 872 operations on cases of gas- 
 tric and duodenal ulcers, with 10 deaths a mortality of 
 1.14 per cent. 
 
 REFERENCES. 
 
 1 Lancet, 1920, i, p. 698. * Annals of Surgery, 1920, i, p. 303. * Journ. Amer. 
 Med. Assoc., 1914, Ixiii, p. 1184. 4 Annals of Surgery, 1919, Ixx, p. 522.
 
 DISAPPOINTMENTS AFTER GASTRO- 
 ENTEROSTOMY 
 
 EVERY operation in surgery, even the best, most ex- 
 quisitely performed, may bring its disappointments. The 
 operation of gastro-enterostomy, carried out in appro- 
 priate cases by a competent operator, is probably the 
 most successful of all surgical procedures of equal magni- 
 tude, and it is certainly among the safest of those entitled 
 to the description of major operations. In my last series 
 of more than 300 non-malignant cases I have not lost a 
 patient, and in recent years a temporarily unsatisfactory 
 result has been extremely rare. 
 
 When we speak of disappointments after gastro-enter- 
 ostomy, we must first remember that it may not be the 
 fault of the operation but of many other circumstances if 
 things go wrong. The success or failure of an operation 
 may be due not only to the procedure itself but also to 
 its performance in cases which did not need it. 
 
 It falls to my lot to see many cases in which the opera- 
 tion of gastro-enterostomy has failed, and in reviewing 
 these I find that they are capable of tabulation in the 
 following manner: 
 
 A. THE OPERATION HAS BEEN PERFORMED IN THE 
 ABSENCE OF ANY ORGANIC LESION JUSTIFYING IT 
 
 This is by far the most frequent cause. In every 
 ten cases of unsatisfactory results nine are due to this 
 cause and to this alone. 
 
 Reprinted from the British Medical Journal, July 12, 1919. 
 HI
 
 112 . ESSAYS ON SURGICAL SUBJECTS 
 
 The conditions for which the operation has been need- 
 lessly performed are two: 
 
 (a) IN FUNCTIONAL DISORDERS OF THE STOMACH 
 
 The more we know of organic diseases of the stomach 
 the fewer do those cases formerly considered functional 
 progressively become. It is not so long since a patient 
 suffering from duodenal ulcer, for example, was fre- 
 quently told that he was the victim of "acid gastritis," 
 or "acid dyspepsia," "hyperchlorhydria," or "neuralgia of 
 the stomach," all of which were said to be functional 
 states. 
 
 When I first called attention to the symptoms and to 
 the clinical diagnosis of duodenal ulcer, I found it difficult 
 to persuade many of my friends that I was speaking of 
 a common organic lesion which could be demonstrated 
 during an operation to any intelligent onlooker. 
 
 To-day every one agrees that these symptoms are in 
 truth due to a structural lesion and not to a vice in the 
 chemistry or a defect in the motility of the stomach. 
 And this holds good of other "functional diseases" of the 
 stomach also. Inquiry upon the operation table reveals 
 organic causes. 
 
 There still remain, however, a number of difficult cases 
 of functional troubles associated with atony of the stomach 
 or prolapse of this and other abdominal organs. Such 
 cases may be difficult to treat by medical means, massage, 
 exercises, and so forth; but they are often made very much 
 worse by the performance of a short-circuiting operation. 
 If such patients vomited before, they vomit still, though 
 the character of the vomit is altered by the addition of 
 large quantities of bile. In a few instances the patients 
 will say that they are neither better nor worse, and I have
 
 GASTRO-ENTEROSTOMY 113 
 
 known one or two who incline to think their condition a 
 little better than it was before operation. But the excep- 
 tions are very few to the rule that in these conditions 
 surgical measures are harmful or disastrous. 
 
 In such patients the only further operative treatment 
 which the surgeon should undertake is the reparation of 
 the mistakes of his too enterprising predecessor. The 
 anastomosis must be undone, and the stomach and intes- 
 tine returned as far as possible to their original condition. 
 If there is a moderate degree of visceral prolapse great 
 relief may be obtained from the application of a Curtis 
 belt or of corsets. 
 
 (6) IN CASES OF CHRONIC DISEASE ELSEWHERE 
 
 For several years I have endeavoured on many occa- 
 sions to emphasize the importance of verifying, after the 
 abdomen is opened, the original diagnosis of ulcer of the 
 stomach or of the duodenum, before beginning any opera- 
 tion designed to relieve the patient of his symptoms. An 
 ulcer of the duodenum or of the stomach, if the cause of 
 symptoms so long continued, or so severe as to justify an 
 operation, is always a visible, demonstrable, palpable 
 lesion. If no ulcer is found no operation should be per- 
 formed. The day is long past wh6n a surgeon is entitled 
 to accept a clinical diagnosis, however confidently made, 
 as a sufficient warrant for an operation. The lesion sup- 
 posed to exist must be recognized at the time the abdomen 
 is opened before any further steps are taken with the 
 intended operation. This rule, which should appeal to 
 every one, is still violated with no little frequency. If no 
 ulcer is found, a search should then be made elsewhere in 
 the abdomen for a possible cause of those symptoms which 
 have been attributed to a chronic ulcer. Failure to ob- 
 
 8
 
 1U ESSAYS ON SURGICAL SUBJECTS 
 
 serve these precautions, and to remember this unalterable 
 rule, has resulted in the performance of gastro-enteros- 
 tomy for conditions remote from the stomach. The 
 operation of gastro-enterostomy has been performed for 
 the following diseases: 
 
 I. CHRONIC APPENDICITIS 
 
 This is the commonest of the mistakes in this class. 
 Many physicians and surgeons have long realized how 
 exact the mimicry of the symptoms of ulcer of the stomach 
 or of the duodenum may be in cases of chronic appen- 
 dicitis. Nine years ago 1 "appendix dyspepsia," a condi- 
 tion in which symptoms closely resembling those due to 
 gastric ulceration were caused by a chronic lesion in the 
 appendix, was described, and special attention was called 
 to the presence of haematemesis or melaena in these cases. 
 Haematemesis is more common in other diseases than in 
 gastric ulcer, of which it is not a very frequent symptom. 
 The occurrence of haemorrhage should therefore raise at 
 once a suspicion not only of ulcer, but of chronic appen- 
 dicitis, splenic anaemia, or cirrhosis of the liver. 
 
 II. TUBERCULOUS DISEASE OF THE INTESTINE 
 
 Tuberculous disease of the ileum, or caecum and 
 ascending colon has been present in a small number of 
 cases where gastro-enterostomy had been performed in 
 the absence of any ulcer of the stomach or duodenum. 
 
 Tuberculous disease of the intestine appears to be a 
 common disorder in England and in Scotland. The im- 
 purity of the milk supply, of course, is responsible for this. 
 Manchester has recently discovered that 35 per cent, of the 
 milk brought to it contains living tubercle bacilli, and
 
 GASTRO-ENTEROSTOMY 115 
 
 a similar alarming discovery could doubtless be made in 
 other towns if inquiry were instituted. The symptoms 
 produced are, as a rule, clear evidence of tuberculous 
 disease; but occasionally a patient may present such 
 symptoms as make a diagnosis of duodenal ulcer not 
 impossible. There are pyloric spasm, hyperacidity, pain, 
 and vomiting. I have found tuberculous disease of this 
 kind in two medical men who believed themselves to be 
 the subject of duodenal ulcer, and whose belief was 
 strengthened by other opinions. Both were a little dis- 
 mayed when they learnt that gastro-enterostomy had not 
 been performed; but both, I am glad to say, are cured 
 by their operations. I have had one patient sent to me 
 as a case of "gastric ulcer" upon whom I performed 
 colectomy for hyperplastic tuberculous disease of the 
 caecum. 
 
 III. CHOLELITHIASIS, OR CARCINOMA OF THE 
 GALL-BLADDER 
 
 Cholelithiasis, in all cases except those in which a single 
 cholesterin stone is present, declares its presence, even in 
 early stages, by the symptoms of dyspepsia, and often also 
 of hyperacidity. The pain of flatulence and of heaviness 
 comes with fair regularity about half an hour after a meal. 
 There may be vomiting, and there is often much complaint 
 of acidity. A very large proportion of the cases of chole- 
 lithiasis, at a time when no colic has occurred, are diag- 
 nosed as cases of gastric disease. 
 
 The way to prevent this, and so many other mistakes, 
 is to examine all parts of the abdomen likely to be affected 
 by disease, before the purposeful part of the operation is 
 begun.
 
 116 ESSAYS ON SURGICAL SUBJECTS 
 
 IV. CIRRHOSIS OF THE LIVER, WITH HEMORRHAGE 
 
 In cirrhosis of the liver there is often dyspepsia; flatu- 
 lence, heaviness, soreness, frequent eructations, with loss 
 of appetite and a foul tongue, are common symptoms. 
 Hsematemesis or melsena, or both, may be profuse. The 
 absence of orderly development and precision in the time 
 and character of the symptoms makes the differential 
 diagnosis between cirrhosis and duodenal or gastric ulcer 
 rarely difficult. 
 
 V. SPLENIC ANEMIA 
 
 I have known a short-circuiting operation to be per- 
 formed in this disease. The haemorrhage is often very 
 abundant. The most copious haematemesis I have ever 
 seen occurred in a patient suffering from this condition 
 upon whom I was asked to operate for duodenal ulcer. I 
 have twice removed the spleen in cases of splenic anaemia 
 from patients who were sent to me as cases of duodenal 
 ulcer. In both no ulcer nor any scar was seen. 
 
 VI. TABES DORSALIS 
 
 I have seen five patients who were operated upon in 
 this disease after a mistaken diagnosis of "gastric ulcer" 
 had been made. The gastric crises, and the other dys- 
 pepsias seen in tabetic patients, have so little akin to the 
 symptoms produced by organic diseases of the stomach 
 that there is no excuse for the mistake. I have had one 
 patient who, suffering from tabes, had also the symptoms 
 of duodenal ulcer. I operated upon him, demonstrated 
 the ulcer, and performed gastro-enterostomy.
 
 GASTRO-ENTEROSTOMY 117 
 
 VII. DISSEMINATED SCLEROSIS 
 
 I have seen one patient with this disease upon whom 
 gastro-enterostomy had been performed; the surgeon 
 found no ulcer, though the symptoms had suggested its 
 presence to him. In the crises of the attacks of pain the 
 stomach became greatly distended. 
 
 VIII. THE VOMITING OF PREGNANCY 
 
 I have known two patients submitted to the operation 
 of gastro-enterostomy for this condition under a mistaken 
 belief that a gastric ulcer was present as the cause of the 
 symptoms. Vomiting is neither a common nor, as a rule, 
 a serious symptom in the great majority of cases of 
 gastric ulcer. 
 
 IX. IN LEAD POISONING 
 
 I have seen one patient upon whom gastro-enterostomy 
 had been performed when neither open ulcer nor old 
 scar could be found. The evidences of lead poisoning 
 colics, blue line on the gums, etc. were quite clear at the 
 later stage. 
 
 X. IN PROLAPSE OF KIDNEY 
 
 Many years ago Sir F. Treves and Sir William Bennett 
 described a group of cases in which a loose kidney had 
 pulled upon the gall-bladder and ducts to such a degree as 
 to cause jaundice. The same drag may be made upon the 
 duodenum and symptoms of pain and vomiting be pro- 
 duced. Loose kidneys comparatively seldom produce 
 symptoms of any consequence, but there is no doubt of 
 the existence of the conditions just described.
 
 118 ESSAYS ON SURGICAL SUBJECTS 
 
 XI. COLIC ADHESIONS 
 
 Many patients who suffer from vague dyspepsias, 
 ascribed perhaps to intestinal stasis, or to chronic appen- 
 dicitis, disclose on the operation table this condition: 
 A membranous band, broad above, where it takes origin 
 from the posterior abdominal wall, the under surface of 
 the liver, the pelvis of the gall-bladder, the cystic duct, 
 and the duodenum, narrows below as it crosses the as- 
 cending colon to be lost on the peritoneum, to the inner 
 side of the ascending colon, and on the enteric mesentery. 
 Below this band, which is quite different from a "Jack- 
 son's membrane," the caecum and the ascending colon are 
 distended and soggy. Very often the appendix looks 
 turgid, thick, and stiff. Removal of the appendix, to 
 which the troubles are ascribed, gives little or no relief. 
 Division of the band allows adhesions to re-form. The 
 only practice likely to give good results is the removal of 
 the terminal ileum, caecum, and ascending colon. The 
 performance of gastro-enterostomy, of course, makes 
 matters worse. 
 
 XII. EPIGASTRIC HERNIA 
 
 A hernia of this kind, however small, may cause teasing 
 and protracted symptoms. The chief complaint is of 
 indigestion, dragging, heaviness, etc. A careful examina- 
 tion for this condition should always be made. 
 
 B. THE OPERATION HAS BEEN INCOMPLETE 
 
 It appears to be still a custom in dealing with duodenal 
 and gastric ulcer to perform gastro-enterostomy only, 
 leaving the ulcer itself untouched, and making no search 
 in the abdomen for other conditions. As these ulcers
 
 GASTRO-ENTEROSTOMY 119 
 
 are probably often, if not always, secondary to some 
 infection which may exist within the abdomen, such a 
 search should be a necessary part of every operation, pro- 
 vided that the condition of the patient will warrant it. 
 Chronic appendicitis is very frequently associated, prob- 
 ably in a causal relation, with ulcers of the stomach and 
 duodenum. It is better, therefore, always to remove the 
 appendix. The division of the membrane which causes a 
 "Lane's kink" may also be practised. The gall-bladder 
 should always be examined for the presence of stones, or 
 of that subserous deposit of fat, especially near the pelvis, 
 and the cystic duct, which is, I hold, the first sign visible 
 from the exterior of an infection of the walls of the gall- 
 bladder from within. Either the removal of stones and 
 drainage of the gall-bladder or removal of the gall-bladder 
 may be necessary. 
 
 But, above all, the ulcer itself should be dealt with 
 in such manner as to secure that all large vessels running 
 into it are ligatured, and that the risk of subsequent 
 perforation is lessened or prevented by the infolding of 
 the ulcer, and by the covering over of the first part of the 
 duodenum by the two omenta. Cases of fatal hemor- 
 rhage from a duodenal ulcer, weeks or months after gastro- 
 enterostomy had been performed, are recorded by Kocher, 
 Quenu, Sir F. Eve, and others. And Mr. Corner has 
 related the story of the fatal perforation of a duodenal 
 ulcer in a patient upon whom I had operated three years 
 before. Other cases of perforation in similar circum- 
 stances are known to me, and some are recorded in the 
 literature. Merely to perform gastro-enterostomy in cases 
 of duodenal ulcer is therefore to leave open many chances 
 of subsequent disaster. A direct dealing with the ulcer is 
 always necessary. In patients upon whom gastro-enter-
 
 120 ESSAYS ON SURGICAL SUBJECTS 
 
 ostomy alone has been performed, there may be a recur- 
 rence of all the original symptoms of duodenal ulcer. In 
 such cases one of two conditions is present either a 
 jejunal ulcer, or a revival of activity in the duodenal ulcer. 
 If the latter, the infolding of the ulcer, and its protection 
 by a double covering of the omenta, wih 1 remove the symp- 
 toms at once. An x-ray examination before the opera- 
 tion will probably show that much of the food passes by 
 the pylorus. I rarely practise either excision of the ulcer, 
 exclusion of the pylorus, or partial duodenectomy and 
 gastrectomy in cases of duodenal ulcer, for the results of 
 the simpler operation of gastro-enterostomy are hardly to 
 be improved. 
 
 The infolding of the ulcer of course narrows the pylorus 
 for a time at least, but it is not with the object of pro- 
 ducing obstruction that the infolding is done. As A. B. 
 Mitchell has shown, the infolded ulcer very rapidly 
 disappears. 
 
 C. DEFECTS IN TECHNIQUE 
 
 The operation has been performed, rightly tr wrongly, 
 and certain technical errors cause distressing symptoms- 
 pain, vomiting, diarrhoea, etc. 
 
 The chief of these occur when 
 
 1. 
 
 The anterior or the posterior operation has been per- 
 formed, and a long jejunal loop has been left. This loop 
 may, with difficulty, be emptied; it may become "water- 
 logged," and an obstruction may develop at the afferent 
 opening into the stomach. "Regurgitant vomiting" 
 occurs, only to be relieved by lavage, or in severe cases 
 by the performance of an entero-anastomosis, which 
 checks it at once.
 
 GASTRO-ENTEROSTOMY 
 
 2. 
 
 With a short or a long loop the efferent piece of jejunum 
 has been blocked as a consequence of a kink, or from 
 adhesions, between the intestine on the one side, and the 
 abdominal wall, omentum, transverse colon or mesocolon, 
 and loops of small intestine on the other. Regurgitation 
 occurs here also. Regurgitant vomiting means high 
 intestinal obstruction. 
 
 3. 
 
 A short-loop posterior gastro-enterostomy has been 
 performed. At the time when the jejunum was lifted up 
 to oppose to the stomach before suture, adhesions were 
 found binding it to the under surface of the transverse 
 mesocolon, an exaggeration of the ligament of Treitz. 
 These were divided and a raw surface left on the jejunum, 
 proximal to the opening made to anastomose with the 
 stomach. Adhesions then formed and caused obstruction 
 of the proximal part of the jejunum between the duodeno- 
 jejunal flexure and the opening into the stomach. Mr. 
 Nicoll, of Glasgow, describes this condition. 
 
 4. 
 
 The jejunum has been rotated round its longitudinal 
 axis at the time when it has been approximated to the 
 stomach. This twist may be quite enough to cause an 
 obstruction. 
 
 5. 
 
 The opening is too small. I have operated upon pa- 
 tients suffering from pyloric obstruction when a short- 
 circuiting operation had been performed a few months 
 before, and have found the opening too small to admit the 
 tip of my little finger. A gastro-enterostomy opening 
 should always be large; not less than 2 in. in length.
 
 122 ESSAYS ON SURGICAL SUBJECTS 
 
 6. 
 
 The opening is badly placed. The opening should 
 always reach the greater curvature and is best placed in 
 line with the oesophagus. Whether the jejunal direction 
 is vertical, as I prefer it, or inclines from left to right or 
 right to left matters very little. 
 
 I have found the opening, originally made too small, 
 lying midway between the curvatures, and in one case 
 actually on the lesser curvature at the incisura. In such 
 cases an x-ray examination will show the existence of 
 a pool of unemptied stomach contents below the anasto- 
 mosis. By manipulation the stagnant fluids can be 
 pressed out of the anastomotic opening. 
 
 7. 
 
 The suture used to effect the anastomosis has em- 
 braced not only the cut edges of the stomach or jeju- 
 num but also a part of the further wall of either one or 
 other or both of these viscera, so that the new opening 
 made between them is much narrowed. I have found 
 this in one case upon which I did the secondary opera- 
 tion for jejunal ulcer. Walton records (Proc. Roy. Soc. 
 Med., 1920, XIII, 180). 
 
 8. 
 
 There has occurred a hernia of the small intestine 
 through the unclosed rent in the mesocolon. In one of 
 my early cases (1902) I did not stitch the cut edges of 
 the opening, made through the transverse mesocolon, to 
 the suture line. A great part of the small intestine 
 escaped through the opening into the lesser sac and be- 
 came strangulated; the patient died. It is, I think, im- 
 portant to close the opening in the mesocolon very care-
 
 GASTRO-ENTEROSTOMY 123 
 
 fully. One of the ablest surgeons in the world told me of 
 a case in which he did not suture the opening very com- 
 pletely, leaving a gap at the proximal end of the jejunum. 
 A small knuckle of bowel crept in and became strangu- 
 lated. An operation on the fifth day revealed the 
 condition. The patient recovered. 
 
 The edges of the mesocolic opening should be sutured 
 either to the stomach or to the suture line. If they are 
 attached to the jejunum alone the stomach may withdraw 
 into the lesser sac, and so cause a kink or obstruction near 
 the stoma. 
 
 9. 
 
 The use of unabsorbable sutures silk, h'nen, thread, 
 thick chromicized catgut. The work of Wilkie seems to 
 show that catgut is to be preferred to any other suture 
 material. It remains long enough to ensure firm union 
 between the viscera, and disappears in a few weeks' time. 
 The catgut should be as fine as is compatible with ade- 
 quate strength. I use the finest chromic gut (000000) 
 for both sutures. 
 
 In many cases of haemorrhage occurring some weeks or 
 months after the operation the liberation of an unabsorb- 
 able suture may be the cause. Such sutures may be seen 
 hanging from the fine of anastomosis when later operations 
 are performed. I have found a piece of stout chromic- 
 ized catgut three years and nine months after the original 
 operation. Of the two sutures it is, I believe, certain 
 that the outer one, the sero-serous, is the one so long 
 retained. The inner stitch, which apposes the cut edges 
 of the mucous membrane, is probably always discharged 
 within a very few weeks, whatever the material of which 
 it is composed. The use of linen and silk is perhaps 
 responsible in some degree for the development of jejunal
 
 124 ESSAYS ON SURGICAL SUBJECTS 
 
 or gastrojejunal ulcers. The sutures have to work 
 their way out, and so delay healing, or start an ulcer 
 at any point. I have twice found small ulcers near the 
 retained knot of an unabsorbable suture. 
 
 10. 
 
 The anastomosis has been not seldom made with a 
 portion of the intestine unsuitable for this purpose; 
 with, for example, a loop of the ileum near the ileo-caecal 
 junction, or even, as in a case related by Walton, with 
 the transverse colon. 
 
 11. 
 
 The anastomoses in two cases upon which I subse- 
 quently operated had been made between the distal 
 pouch of an hour-glass stomach and the jejunum. The 
 operation so far as the mere junction of viscera was con- 
 cerned had been well done, but as the obstruction into 
 the distal pouch was unrelieved the operation did no 
 good whatever. 
 
 12. 
 
 Ventral hernia may follow an imperfect closure of the 
 abdominal wound; or after any closure if there be per- 
 sistent, severe coughing or vomiting. 
 
 D. LATE COMPLICATIONS MAY DEVELOP AFTER AN 
 OPERATION PERFORMED, IN A CASE REQUIRING 
 IT, WITHOUT ANY TECHNICAL FLAW. 
 
 1. Jejunal Ulcer 
 
 This is by far the most serious of all the sequels of 
 gastro-enterostomy. The ulcer may be at the suture line, 
 or near it; it is generally small, and, as a rule, is single. 
 
 Its causes are not known with certainty. Among them 
 are, probably, the use of unabsorbable sutures, inaccurate
 
 GASTRO-ENTEROSTOMY 125 
 
 apposition of mucous membrane, bruising of the part of 
 the viscera embraced by clamps with the result that a 
 haematoma forms, a continuance of the cause of the 
 original duodenal or gastric ulcer, and a persisting hy- 
 perchlorhydria. 
 
 It may at least be said that an avoidance of these faults 
 or treatment of these conditions will almost certainly 
 prevent the development of any fresh ulceration. The 
 diagnosis of jejunal ulcer is not, as a rule, at all difficult. 
 There are several clinical types which I have described 
 in my book Abdominal Operations. There are several 
 methods of operative treatment, not all of them satis- 
 factory and some of them very difficult. Recently I have 
 performed partial gastrectomy in such cases, removing the 
 stomach up to the proximal side of the anastomosis, and 
 all that part of the jejunum engaged in the junction. 
 
 The proximal end of the distal limb of the jejunum is 
 closed and the side of it united to the cut end of the 
 stomach; the distal end of the proximal segment is 
 united to the distal portion of the jejunum just below the 
 anastomosis with the stomach. I have known jejunal 
 ulcer to develop in two patients after gastro-enterostomy 
 performed in the absence of any lesion in the stomach or 
 duodenum. 
 
 2. Carcinomatous Change in a Chronic Gastric Uker 
 
 This may occur after an operation which has, for a 
 time, seemed perfectly successful. I have now in my 
 wards a patient upon whom I performed gastro-enteros- 
 tomy for chronic gastric ulcer thirteen years ago. At the 
 time of the recent operation a carcinomatous ulcer was 
 present at the site of the former simple ulcer. In earlier 
 days I have met with several cases in which malignant dis-
 
 126 ESSAYS ON SURGICAL SUBJECTS 
 
 ease developed at the site of a chronic ulcer after operation. 
 In the cases in which the cancer is found within, say, 
 three or four years it may fairly be argued that the growth 
 was present at the time of operation, for gastric cancer 
 may increase very slowly. But in cases occurring later 
 than this the great probability is that the change from a 
 simple to a carcinomatous condition has taken place. 
 
 Nowadays I perform, as a rule, only two operations for 
 cases of chronic gastric ulcer. If the ulcer is not near the 
 oesophagus, and is of average or small size, I perform 
 partial gastrectomy. If the ulcer is very large, burrowing 
 deeply into the liver or the pancreas, and near the cardiac 
 end of the stomach, I perform gastro-enterostomy in Y, 
 and into the proximal limb of the jejunum, below the 
 duodeno-jejunal flexure, I introduce a tube, performing 
 jejunostomy. Through this tube the patient is exclu- 
 sively fed, for few or many months, until an x-ray ex- 
 amination suggests that the ulcer is healed. 
 
 In the case of the largest gastric ulcer I have ever seen, 
 the ulcer occupying the whole of the lesser curvature and 
 extending deeply into the liver, the patient did not take 
 one spoonful of food or drink by the mouth for two years 
 and nine months. I gave her permission to do so at the 
 end of two years, when the ulcer appeared to be healed, 
 but she prolonged at her own desire the period of jejunal 
 feeding for nine months. 
 
 The remembrance of her intense suffering before the 
 operation, and her perfect comfort and satisfaction when 
 she took food only by the tube, weighed with her in making 
 this decision. The jejunostomy opening has been closed 
 for nearly three years, and she remains perfectly well, free 
 from pain, and is now 4 st. heavier than when the original 
 operation was performed.
 
 GASTRO-ENTEROSTOMY 127 
 
 Symptoms after Unsuccessful Gastro-enterostomy 
 
 The symptoms present in cases of unsuccessful gastro- 
 enterostomy are chiefly four pain, haemorrhage, vomiting, 
 diarrhoea. 
 
 Pain may be due to: 
 
 1. A revival of activity in an unhealed ulcer. 
 
 2. The presence of a jejunal ulcer. 
 
 3. Adhesions crippling the proper action of the 
 stomach or jejunum. 
 
 4. The presence of some other disease which has 
 been overlooked at the operation chronic appen- 
 dicitis, cholelithiasis, and the other diseases enu- 
 merated above. 
 
 Haemorrhage may be due to : 
 
 1. The separation of a suture. 
 
 2. Continuing activity in a duodenal or gastric 
 ulcer. 
 
 3. A jejunal ulcer. 
 
 4. The presence of some other disease which has 
 been overlooked, such as splenic anaemia, cirrhosis 
 of the liver, etc., as enumerated above. 
 
 Vomiting may be due to: 
 
 1. Obstruction as a result of any of those technical 
 defects in the operation which I have already named. 
 
 2. Functional causes. 
 
 Diarrhoea may be due to: 
 
 1. Too rapid emptying of the stomach. 
 
 2. Some pathological condition of the intestine, or 
 other viscera, which has been overlooked. 
 
 3. The offensive character of the escaping contents.
 
 128 ESSAYS ON SURGICAL SUBJECTS 
 
 The too rapid emptying of the stomach is sometimes a 
 cause, or is supposed to be the cause, of many discomforts, 
 intestinal uneasiness and turmoil, and diarrhoea. When a 
 patient suffering in this way is examined by the x-ray the 
 stomach is seen to empty itself very rapidly perhaps 
 in ten or twenty minutes, the food flowing through the 
 opening into the intestine simply by the act of gravity. 
 In the great majority of such cases that have come within 
 my own knowledge the operation of gastro-enterostomy 
 should not have been performed. The stomach which acts 
 or fails to act, is generally a feeble, flabby atonic organ, 
 capable of exercising little or no control on its contents. 
 The fault here is due to the performance of the operation 
 in an unsuitable case. The jejunum below the opening in 
 such cases appears, by x-ray examination and on inspec- 
 tion, to be dilated as a result of the rapid filling; its 
 distension may be the cause of great distress. 
 
 As I have said, pathological conditions which have 
 escaped notice may be the cause of a continuing diarrhoea ; 
 of such cases are tuberculous disease of the ileum or 
 caecum, or carcinoma of the ascending colon. 
 
 Diarrhoea may also occur within two or three weeks of 
 the operation, and last a few days, or even a month or two, 
 rarely more. This is especially noticeable in cases of 
 malignant disease of the stomach causing obstruction, 
 and is probably 'due to the unchecked escape into the 
 intestine of putrid matter from the stomach, an intense 
 intestinal irritation being the result. 
 
 In a few patients upon whom gastro-enterostomy has 
 been performed with the usual striking success an occa- 
 sional attack of diarrhoea may occur; the stools are liquid 
 and green in colour and irritating to the rectum. In other 
 patients it may be noted that the stools are often clay-
 
 GASTRO-ENTEROSTOMY 129 
 
 coloured, or almost colourless. In such cases the dis- 
 comfort is trivial and temporary, and does not detract 
 from the otherwise excellent result of the -operation. 
 
 CONCLUSION 
 
 The enumeration of all these untoward events in con- 
 nexion with the operation of gastro-enterostomy appears 
 very formidable. But compared with the excellent results 
 of the operation performed in appropriate conditions, and 
 in a skilful manner, the disappointments are nowadays 
 extremely few. Many of the errors to which allusion has 
 been made are probably things of the past. For their 
 avoidance the greatest care in preliminary investigation is 
 necessary. The diagnosis of duodenal ulcer is rarely diffi- 
 cult; the diagnosis of gastric ulcer is never easy. A very 
 large majority of patients supposed to be suffering from 
 "gastric ulcer" are in truth suffering from other diseases. 
 There is only one unequivocal method of diagnosis in cases 
 of gastric ulcer, and that is by x-ray examination. The 
 clinical symptoms are very treacherous. 
 
 But when the operation is begun no clinical diagnosis, 
 however confidently made, can stand against the con- 
 ditions revealed then to the hand and eye. If an ulcer is 
 not seen and cannot be demonstrated, it does not exist, and 
 therefore no operation designed for its cure or relief should 
 be performed. A search must then be made elsewhere. 
 And remembrance should always be given to the asso- 
 ciated and interrelated actions of such organs as the liver, 
 spleen, pancreas, and the alimentary canal. 
 
 REFERENCES. 
 1 British Medical Journal, 1910, i, p. 241.
 
 INTESTINAL STASIS* 
 
 IN a discussion upon "intestinal stasis" a single 
 speaker can touch only very lightly upon any particular 
 aspect of this most interesting problem. The literature 
 which has already accumulated is so vast, and the claims 
 made as to the importance of the condition are so far 
 reaching, that anything in the nature of a close criticism 
 of the matter having regard to brevity is impossible. 
 
 It is asserted: (a) that certain bands, webs, veils, or 
 membranes are present at defined points in the alimentary 
 canal; (6) that these adhesions are responsible for delay 
 in the onward transmission of the intestinal contents, and 
 consequently for increased decomposition in them; and 
 further, that the organisms so proliferating, or other 
 noxious products, are absorbed into the system and pro- 
 duce certain deleterious effects; (c) that certain disorders 
 are due exclusively to the toxaemia which comes from such 
 absorption, or from subinfection, and that a very large 
 number of the diseases to which man is liable are also 
 harmfully influenced thereby. 
 
 What truth is there in these various statements? 
 Of the existence of various membranous adhesions along 
 the course of the alimentary canal there can be no doubt. 
 Between the duodenum and the gall-bladder or the under 
 surface of the liver, at the duodeno-jejunal flexure, at the 
 end of the ileum, along the ascending colon, at the hepatic 
 and splenic flexures, and to the outer side of the pelvic 
 
 * Spoken before the Clinical Congress of Surgeons of North America, London, 
 July 31, 1914. 
 
 Reprinted from Surgery, Gynecology, and Obstetrics, February, 1915. 
 
 131
 
 132 ESSAYS ON SURGICAL SUBJECTS 
 
 colon they are plainly and frequently to be seen. There 
 origin is not yet certainly ascertained, and it may indeed 
 not always be the same. Certainly many of them are 
 congenital. When in 1899 I published my work on 
 "Retroperitoneal Hernia," I had examined the abdomens 
 of a large number of foetuses, children, and young adults, 
 in order to discover the number, nature, and extent of the 
 peritoneal fossae. I found, and there recorded, the fact 
 that adhesions of the proximal jejunum and the terminal 
 ileum were not seldom found in these case, and that they 
 were due to the condition described by Toldt as "physio- 
 logical fusion." The membrane which binds the ascend- 
 ing colon so loosely to the posterior abdominal wall- 
 Jackson's membrane, as it is called, though Lane not only 
 described but depicted it has a vascular supply of such 
 regular appearance that it seems impossible that it should 
 be anything other than a developmental relic. The origin 
 of the band at the hepatic flexure, and of the more obvious 
 and thicker string-like adhesion at the splenic flexure, is 
 probably, as Lane asserts, the result of traction and the 
 effort to restrain or overcome its effects. Of the existence 
 of these several membranes, therefore, there is no doubt. 
 There is little doubt, also, that they are for the most part 
 congenital though mild inflammatory processes; or the 
 response of the parts to dragging force applied to them 
 may be responsible for their increased developemt. If 
 the supports of the bowel were in need of reinforcement it 
 is probable that strength would be added to membranes 
 already existing rather than that entirely new bands 
 should be laid down. When once these adhesions are 
 formed they may, of course, hamper the free action of the 
 intestine. 
 
 It is often said that in cases of intestinal stasis an
 
 INTESTINAL STASIS 133 
 
 obstruction exists at the site of one or another of these 
 bands, and that long delay of the contents of the bowel 
 is caused thereby. This does not tally with the general 
 operative experience. Every surgeon who has much 
 experience of the intestine in these cases will agree that, 
 as a rule, the wall of the gut is thin and almost translucent; 
 it is not, as we see it in cases of veritable obstruction, thick 
 from hypertrophy of its muscular wall. It is feebleness 
 of action rather than impediment which causes the tedious 
 transit of food. The walls of the gut are thin, the mem- 
 branous supports are of such poor quality that parts 
 normally well-fixed like the splenic flexure can often be 
 withdrawn from the abdomen, and the musculature of the 
 abdominal wall is flaccid and feeble. Everything indicates 
 that a sort of apathy is, as a rule, the cause of stagnation, 
 not an obstruction which is with difficulty overcome. 
 
 We may therefore take it as proved that the various 
 bands described in connection with the intestine do exist, 
 though we may dispute as to their origin; we may agree 
 also that undue delay in the forward transmission of the 
 intestinal contents does occur, and that this delay is 
 accompanied either by a form of subinfection, by organ- 
 isms in varying degrees of attenuation escaping from the 
 intestine, or by a form of intoxication. 
 
 What are the clinical results of all this? In the 
 recognition of a certain type of patient whose ills are solely 
 dependent upon intestinal stasis we shall all probably be 
 in agreement. The victim of what we may call "Lane's 
 disease" is now easily recognized, and the symptoms are 
 caused to disappear by appropriate surgical treatment. 
 The symptoms are strikingly repeated in case after case. 
 The patient is generally a woman of unhealthy aspect 
 and attenuated figure. She is lean, cadaverous, flat-
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 chested, and she has a sour breath and cold and clammy 
 hands. The skin is harsh and of an earthy colour and bears 
 many crops of pimples; its secretion is apt to be distress- 
 ingly noticeable. She makes complaint of "indigestion," 
 pain after meals, flatulence, and inveterate and incoercible 
 constipation. The abdominal muscles lack bulk and 
 tone. They are flabby and flaccid, and all the viscera 
 which they should hold up are fallen in greater or less 
 degree. Mentally, there is often a complete absence of 
 the joy of life: the patient is a morose, querulous, and 
 often suspicious and introspective person. These at- 
 tributes are rarely all present together, but so many of 
 them may coexist as to enable a distinct type of patient 
 tojbe recognized. In the very obvious cases of this kind 
 I do not think the mild measures that can often usefully 
 be employed for the novice massage, abdominal exer- 
 cises, and the unrestricted use of paraffin are really of 
 any value. These sufferers are properly cases for surgical 
 treatment. The colon should be excised in whole or in 
 part. In some, perhaps, ileosigmoidostomy may be done ; 
 but in every case, with one exception, in my own series 
 there has been some regurgitation of the intestinal contents 
 upward along the descending colon to the caecum. The 
 stasis then is worse than before, for a mass of faecal 
 material that is never wholly dislodged is palpable at all 
 times. The symptoms, which are nevertheless relieved 
 in great measure, are clearly not due merely to the 
 stagnation of the bowel contents. No method of anas- 
 tomosis, nor any fashioning of new kinks, can wholly 
 prevent this backward flow, though something can doubt- 
 less be done to lessen the tendency to it. Personally, I be- 
 lieve that nothing short of colectomy offers a substantial 
 chance of cure. How much of the colon is to be removed?
 
 INTESTINAL STASIS 135 
 
 This invites a consideration of the function of the large 
 gut. It is well known that putrefaction goes on much 
 more largely in the lower ileum than in the large intestine; 
 but it is not improbable that in the caecum and ascending 
 colon absorption takes place more freely. The liquid 
 contents delivered through the ileocaecal valve are moved 
 backward and forward in the ascending colon and rapidly 
 lose a good deal of the fluid matter. "We drink with the 
 large intestine." The ascending colon has possibly other 
 uses: of excretion or even of internal secretion. The 
 hind gut, which begins in some part of the transverse 
 colon supplied from the anastomosis magna of Riolan, is 
 only for the storage and expulsion of the faecal masses full 
 of bacteria, mostly dead, delivered to them. The part 
 of the gut that needs removal is therefore, I think, the last 
 part of the ileum, the caecum, and the ascending colon. 
 Accordingly, in such patients who need surgery I prefer 
 to resect these parts of the bowel. 
 
 It is, on the whole, an advantage to have the descend- 
 ing colon and the pelvic colon left. Absorption barely 
 goes on at all from these parts, for we know that a simple 
 injection of saline fluid introduced into the rectum rapidly 
 finds its way around to the caecum. If the descending 
 colon and the sigmoid flexure are too lengthy, a suggestion 
 of Sir H. M. Gray's may be adopted. Making use of the 
 principles of mobilization and displacement, to which I 
 called attention, he loosens the hind gut from its moorings 
 and displaces it upward ; so that what was the pelvic colon 
 becomes now the descending colon, and the latter is made 
 to occupy the place of the transverse colon. This opera- 
 tion is simple, very satisfactory in its results, and in my 
 hands has, as yet, had no mortality. Its advantages 
 over complete removal of the colon appear to be that all
 
 136 ESSAYS ON SURGICAL SUBJECTS 
 
 the maleficent part of the intestinal tract is removed, and 
 that enough of the bowel remains to avoid the teasing and 
 troublesome diarrhoea which is known to follow so fre- 
 quently upon the larger operation. Moreover, the num- 
 ber of raw stumps of ligatured vessels is fewer, and their 
 "peritonization" is far more complete than when all the 
 colon is taken. Finally, some of the omentum is left, 
 and in a territory given over at times to riot the presence 
 of the "abdominal policeman" is possibly a witness to 
 peace. It is known that a great menace, perhaps the 
 greatest, attaching to the operation of complete colectomy 
 is the occurrence of obstruction afterward. The raw 
 surfaces left by so great a denudation of the posterior 
 abdominal wall, and by the vessels which have been tied 
 in the various mesenteries, afford easy opportunity for 
 tethering adhesions to form and cause obstruction. Ileo- 
 colic resection allows of very adequate "peritonization" 
 of all the rough places left and closure of the gaps be- 
 tween the divided ends of the mesentery. 
 
 The patients whose condition and appearance I have 
 just described very often undergo a most marvellous 
 rejuvenation after operation. They gain in weight and 
 glow with health; life changes its colour, and vivid in- 
 terest and keen enjoyment succeed to apathy and lan- 
 guor. 
 
 In dealing with the clinical aspects of intestinal stasis 
 we are, so far, upon firm ground. We can pick no quarrel 
 with the enthusiasts. What further part does intestinal 
 stasis play as a causative factor in any disease? What 
 influence has it, for example, upon the development of 
 gastric and duodenal ulcer, and upon the various phases 
 of cholelithiasis? 
 
 Many surgeons have realized, and some of us long have
 
 INTESTINAL STASIS 137 
 
 taught, that in a great many cases these common dis- 
 orders of the upper abdomen are not to be considered as 
 isolated and primary diseases; the view should rather be 
 held that they are secondary expressions of a primary 
 lesion elsewhere, and that they are often linked together 
 by a common antecedent, if not evoked by a common 
 cause. There is much evidence to show that they are 
 secondary to some infection, within or without the ab- 
 domen. For some years past I have held the view that 
 the appendix is the test-tube in which organisms are 
 propagated which, by a process of subinfection, express 
 their ravages in the form of ulceration in the stomach or 
 in the duodenum. A gall-stone, as we know, is merely 
 an invading army of organisms coated by the missiles 
 with which they have been bombarded. Sir Arbuthnot 
 Lane believes that the chronic inflammation of the ap- 
 pendix itself is also secondary the result of the causes 
 which are associated also with stasis in the intestine. I 
 regret that I cannot accept his view as tenable, except 
 in a small proportion of the cases. In the great majority 
 we do not find intestinal stasis, nor the Lane kink or veil, 
 nor, indeed, any of the customary evidences of intestinal 
 stasis to which he has called attention, whereas we do 
 find the most positive evidence of appendicular disease. 
 For the last few years when operating for a chronic 
 gastric or duodenal ulcer or for gall-stones, I have made, 
 in all proper cases, a careful search at the site of the various 
 obstructing membranes we now so easily recognize, and 
 I am compelled to assert that the evidence of stasis, or of 
 the demonstrable conditions upon which it so often de- 
 pends, is not to be found in more than a very small 
 proportion of the cases. Moreover, the recovery of the 
 patient who, for example, has had gastro-enterostomy done
 
 138 ESSAYS ON SURGICAL SUBJECTS 
 
 for a duodenal ulcer, is so speedy, so complete, and so 
 enduring that it is a sheer impossibility that any lingering 
 disease remains behind. We must put this matter defi- 
 nitely, for recently I have heard of patients with de- 
 clared duodenal ulcer who have lost their lives through 
 operations directed to the relief not of the ulcer, but of a 
 wholly suppositions intestinal stasis. For gastric ulcer, 
 for duodenal ulcer, and for cholethiasis no operation 
 should be sanctioned which does not deal directly with 
 the parts involved. To perform colectomy or ileosigmoid- 
 ostomy in such cases is, I think, to exceed our right and to 
 neglect our plain duty. 
 
 So far as concerns a great variety of other diseases, it is 
 claimed that intestinal stasis is either the sole cause or a 
 contributory cause of such significance that all other 
 causes can be neglected or dismissed. 
 
 In diseases of the joints, for example, rheumatoid 
 arthritis, or tuberculous disease, stasis is held to be the 
 essential indispensable factor causing the harm, or at least 
 permitting it to take place. And the treatment of the 
 severer forms, at least, of both diseases does not occupy 
 itself with a direct assault upon the joints affected, but 
 with the intestine from which ah 1 the evil has started. 
 Cases are reported, and are shown to us, in which such 
 treatment has had an effect beyond all one's wildest 
 imagining. I have myself seen many cases of advanced 
 indeed, apparently hopeless tuberculous disease of the 
 hip-joint, or of the wrist or shoulder, in which an arrest 
 of the quickly destructive processes took place almost at 
 once when the colon was removed or a short-circuiting 
 operation performed. And a sensible improvement has 
 followed also in a few cases of rheumatoid arthritis in 
 which, while nothing was done directly to the joint, the
 
 INTESTINAL STASIS 139 
 
 whole colon was excised. Of the occurrence of such events 
 there can be no question. They do not, indeed, stand 
 alone. Rheumatoid arthritis, as we all know, is a disease 
 with many causes, with many aspects, with many vagaries, 
 and with many equal responses to many different forms 
 of treatment. We know little of the disease except that 
 it is often, possibly always, the result of a chronic in- 
 fective process at work somewhere in the body, producing 
 effects at a distance. In the old days of surgery the 
 earliest certain manifestation in pyaemia was the affection 
 of distant joints. Rheumatoid arthritis is pyamia mov- 
 ing slow r ly. Probably every surgeon knows something of 
 chronic joint diseases which undergo striking improvement 
 when factories of infection are closed down. I have cured 
 not a few cases of "rheumatoid arthritis" by draining or 
 removing the gall-bladder, which produced the poisons 
 to which the joints reacted. Of the occurrence of a few 
 equal improvements after colectomy I am fully cogni- 
 zant; but I am also aware of many cases that have 
 showed little or no permanent relief. 
 
 Of the tuberculous diseases of the joints the same may 
 be said. Without question, there is some improvement 
 in some cases, much improvement or even cure in a few. 
 But the bulk of the cases, so far as I can judge, are not 
 appreciably affected by operation upon the intestine. 
 Moreover, I have known of cases in which tuberculous 
 disease of the hip developed after ileosigmoidostomy had 
 been performed, and it is at least of some interest to 
 know that a patient upon whom colectomy was done 
 fell a victim afterward to phthisis, from which, however, 
 recovery took place. 
 
 The evidence at the moment available allows us cer- 
 tainly to say that intestinal stasis does seem to stand in
 
 140 ESSAYS ON SURGICAL SUBJECTS 
 
 a causal relationship toward some cases of chronic joint 
 affections, and that such cases exhibit a marked and in- 
 stantaneous delay or even cessation in the destructive 
 processes, after operation upon the bowel, and that a 
 complete recovery of the joint ultimately occurs. What 
 is uncertain is not the existence of such cases, but their 
 frequency. So little has been done in this direction, and 
 so few surgeons have lent themselves to this form of 
 treatment, that we cannot do other than withhold a 
 confident opinion. The experience of the few, however, 
 is worthy of a wider proof at the hands of other surgeons, 
 in carefully selected cases. 
 
 But the enthusiasts ask us to travel with them even 
 further than this. We are told that a very large number 
 of diseases need have but little attention paid to their 
 local outcry. This should call attention not to the seat 
 of pain, but to its cause, which lies in the intestine. To 
 name a few of these diseases is to show the length to which 
 we are invited to go. Exophthalmic goitre, trigeminal 
 neuralgia, various forms of functional and organic disease 
 of the heart, diseases of the breast, of the thyroid gland, 
 of the pelvic organs of the female, and finally cancer; 
 these are only a few of the diseases which are due, it is 
 said, to stasis in the intestine. The claims are many, the 
 proofs few. We ask for evidence, and if we know some- 
 thing of the work that has been done and of the really 
 striking results that have already been achieved, we shall 
 be prepared to consider the evidence, absurd though it 
 may appear at first, with an eager anxiety to do justice to 
 new views. 
 
 In medicine the new idea is slow to gain currency. 
 We are a conservative race; and we all find criticism a 
 more facile process than creation. Recent experiences
 
 INTESTINAL STASIS 141 
 
 in more than one branch of medicine will hardly persuade 
 us to change our faith. Too much is claimed for every 
 new advance. Vaccines were to rid us of many diseases; 
 now the removal of the colon is to check all diseases that it 
 does not cure outright. In the face of such exaggerated 
 pretentious we do well, perhaps, to go warily ; but we must 
 surely go with open minds. For there is no intellectual 
 sin more deadly than sloth of the imagination. I have 
 thought many hours, read much, and worked not a little 
 at this subject of intestinal stasis, and have tried to clear 
 my eyes for the new vision opened to us by Sir Arbuthnot 
 Lane. My experience has been full of surprises: old 
 beliefs, so slow to perish, have been undermined, and new 
 faiths, so slowly fashioned, have been painfully accepted. 
 And now I do not hesitate to say that the whole question 
 is one which will have to be considered by all of us and to 
 be put to the proof. It cannot be dismissed with a 
 shrug or a sneer, for there is truth in the matter. .Among 
 much that is dross there lies a nugget of pure gold.
 
 ACUTE EMERGENCIES OF ABDOMINAL 
 DISEASE 
 
 THE subject of my address to you to day is one which 
 has been chosen for us by your President, and the choice 
 has my warm approval. It may perhaps be thought by 
 some that it is already rather a hackneyed one, that the 
 matter has been so often and so plainly discussed that little 
 or nothing new or helpful remains to be said, and that 
 hardly any further lessons remain to be learnt. If happily 
 that were so, we should, I am sure, hear less of the matter; 
 we should be less often shocked by the untimely loss of a 
 valued life; and the awful death-roll of abdominal diseases 
 would be greatly curtailed. It is in medicine as in finance 
 much poverty and much paper may coexist. It is not 
 the settled problems of medicine about which much is 
 written, it is rather concerning those matters of which 
 many things still need to be made clear. And so far as 
 this question of the acute abdominal catastrophes is con- 
 cerned, I feel that we are not yet in possession of the real 
 secret of prevention, which is most important of all, of 
 early diagnosis or even of treatment. There is much that 
 has yet to be written for our admonition; there is still a 
 great deal diligently to be learnt. 
 
 The most formidable and the most frequent of ah 1 the 
 acute emergencies in abdominal disease is concerned with 
 the vermiform appendix. An acute attack of inflamma- 
 tion in that organ, attended by gangrene or followed by 
 perforation, is still the most common cause of a catas- 
 trophe, placing the life of the patient in instant jeopardy, 
 
 Reprinted from the British Medical Journa/.fApril 1, 1911.
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 and needing for its certain and most speedy relief the 
 immediate intervention of the surgeon. I believe firmly 
 that the serious characters and the terrible fatality of this 
 disease are due very largely, if not exclusively, to the 
 measures which are, with the best intentions but with 
 profoundest unwisdom, directed to the relief of those 
 earliest manifestations of the disease, the full significance 
 of which is hardly yet appreciated. 
 
 Of the functions of the appendix we know almost 
 nothing, but that they are of some real significance is 
 probable from the fact that the vascular supply of this 
 little tube is considerable and apparently out of all pro- 
 portion to its size or manifest importance. The appendix 
 communicates by a valvular opening with the interior of 
 the caecum at a point an inch or more beyond the ileo- 
 caecal valve. At this valve and in the lowest part of the 
 ileum there is a development of the circular muscular 
 fibres of the intestine to a degree which results in the 
 formation of a sphincter muscle. The anatomical arrange- 
 ment of the pyloric sphincter with the opening of the 
 diverticulum of Vater at the beginning of the small 
 intestine is in some degree reproduced here at the begin- 
 ning of the large, and, though identity of architecture 
 need not mean similarity of function, it seems reasonable 
 to suppose that the glairy mucoid secretion of the appendix 
 possesses some small digestive power. This function, 
 however, is not to be condemned as trivial and without 
 value because ablation of the appendix involves no 
 digestive losses, for I can recall more than one case of 
 permanent biliary fistula in the old days when every drop 
 of bile was discharged on to the abdominal wall and was 
 lost to the economy. In spite of this, there was no 
 apparent diminution in bodily health or weight or ca-
 
 EMERGENCIES OF ABDOMINAL DISEASE 
 
 pacity; yet no one was disposed to deny the value of this 
 copious secretion. Because we do not know the use 
 of the appendix and are unable to measure its func- 
 tion, we are not rashly to condemn it as devoid of worth. 
 The position of the appendix at the junction of the small 
 and large intestine is also noteworthy. The small in- 
 testine, as we know, is concerned almost exclusively in 
 the digestion and absorption of solid matters from the 
 food. The solid particles which are to be absorbed first by 
 one side and then by the other of the valvulae conniventes, 
 as they are waved to and fro (and so filled and emptied) by 
 peristaltic action, must be kept in suspension. If fluid 
 were taken up in the small intestine there would be no 
 vehicle for the conveyance of the solid matter downwards, 
 and vast and various changes would be needed in the 
 structure of the alimentary canal. It is roughly computed 
 that only 10 per cent, of the fluid taken by the mouth is 
 absorbed before the caecum is reached. In the ascending 
 and transverse colon water is freely taken up, and the 
 faecial residue is stored, till a convenient moment for dis- 
 charge, in the sigmoid flexure. The fore-gut prepares the 
 food, the mid-gut digests and absorbs it, the hind-gut 
 stores and expels it. The mid-gut extends from the sec- 
 ond part of the duodenum to the left end of the trans- 
 verse colon; and the function is so divided that the small 
 intestine appeases our hunger, the large intestine slakes 
 our thirst. It is known that fluid taken by the mouth 
 speedily excites a wave of peristaltic activity in the lowest 
 ileum. In cases of typhlotomy or of enterostomy, in 
 which the caecum or lowest ileum is opened, it can con- 
 stantly be observed that the drinking of a little fluid 
 excites a considerable disturbance in this region. I have 
 
 elsewhere quoted instances to prove how excitable this 
 10
 
 146 ESSAYS ON SURGICAL SUBJECTS 
 
 part of the bowel becomes in response to the swallowing 
 of fluids. If the interior of the caecum and the mouth 
 of the ileo-caecal valve be visible (as in cases of typhlotomy) 
 the increasing activity of the appendix, when water or 
 other fluids are freely given, can be constantly witnessed, 
 and never fails to excite wonder and surprise. 
 
 It has been shown by Harvey Gushing, Gilbert and 
 Domenici, and others that the bacteria in the alimentary 
 canal are most numerous and of greatest activity at the 
 junction of the large intestine and the small. Harvey 
 Gushing has also shown that starvation will render sterile 
 all those parts of the intestine which can be caused to 
 empty. On the other hand, it is also well proven that the 
 administration of any aperient medicine not only excites 
 a greater tumult of activity in the small and large in- 
 testines, but that secretion is more profuse and the 
 bacterial virulence throughout the canal is considerably 
 augmented. These points also can be corroborated by the 
 examination of the patients upon whom typhlotomy has 
 been performed. In order that we may see the bearing of 
 these facts upon cases of appendicitis, let me recount to 
 you the type history of a patient attacked by this disease. 
 The first symptom in an attack of acute appendicitis is 
 pain. It is always pain, and never sickness or vomiting, 
 nor malaise, nor any other symptom whatever. If pain 
 should not be the inaugural symptom in a case of acute 
 abdominal illness, the possibility of the appendix being at 
 fault may definitely be excluded. The pain is absolutely 
 abrupt in onset, it is of varying degree of severity, is often, 
 indeed, usually at first referred to the epigastrium, but 
 after the lapse of a few hours becomes, as a rule, distinctly 
 worse in the right iliac fossa. The pain may be rapidly 
 followed by a rigor or a sharp elevation in temperature, by
 
 EMERGENCIES OF ABDOMINAL DISEASE U7 
 
 vomiting, and frequently by diarrhoea. A slight elevation 
 of temperature occurs without exception in cases of appen- 
 dicitis in the early stages. The symptoms one and all 
 show a tendency to steady abatement if proper treatment 
 is adopted, if the patient is denied food of all kinds, 
 fluid or solid, and if aperients are strictly and sternly 
 withheld. It seems to be the natural and instinctive 
 desire of the mother, wife, or nurse in such a condition 
 to administer forthwith a brisk purgative. It is held that 
 something has "disagreed" with the patient, and the 
 offending substance is to be sharply expelled. Castor oil 
 is the usual remedy in the district where I practise, and 
 it is administered unsparingly. It is no uncommon thing 
 to be told that because the first dose was vomited (a most 
 proper act of rebellion on the part of the stomach) 
 a second, or it may be a third, has been given. A few 
 hours after the aperient is swallowed, frequently in the 
 early hours of the morning, the patient is seized suddenly 
 with a new and more intolerable agony, vomiting occurs, 
 and diarrhoea may be repeated. The abdominal wall 
 becomes rigid, tenderness spreads rapidly across the lower 
 part of the belly, and at last is everywhere present; the 
 pulse rises steadily, and all the signs and symptoms of an 
 acute peritonitis are ushered in without delay. When an 
 operation is performed, a gangrenous appendix, very 
 probably adherent near its attachment to the caecum, is 
 found, and the peritoneum, already extensively and 
 severely attacked by an acute inflammatory process, 
 replies to the insult by pouring out freely a thin, clear, 
 sterile, and actively bactericidal fluid. It is now about 
 seven years since I was first brought firmly to the con- 
 viction that in cases of appendicitis it is the administra- 
 tion of an aperient that is responsible for the acute
 
 1U8 ESSAYS ON SURGICAL SUBJECTS 
 
 catastrophe of gangrene and perforation which ends in an 
 acute peritonitis. I do not remember one single case 
 that I have operated upon since in which it was not 
 perfectly clear that the same sequence of events pain, 
 aperient, perforation had occurred, and I therefore do 
 not hesitate to say that in almost every instance of acute 
 peritonitis due to the perforation of an appendix it is 
 the treatment directed to the relief of the condition tjjai 
 is the cause of the serious and so often fatal catastoophe. 
 The taking of a purgative medicine is somethjzig more 
 than an impressive antecedent it is, in my judgement, a 
 definite cause. The only possible exceptions occur in 
 those rare cases where direct violence gives rise to a 
 rupture of the appendix or the laceration of the adhesions 
 which enwrap it. In cases of appendicitis, however acute 
 their origin may be, perforation followed by an acute 
 general peritonitis does not seem to occur if no aperient 
 is given and if absolute starvation is adopted from the 
 first. The acute spreading or general peritonitis which 
 occurs in this disease is due to treatment; it is a "thera- 
 peutic peritonitis." I am quite prepared to learn that 
 this emphatic statement is received with a shrug of doubt 
 and the tolerant smile of disbelief, but if strict enquiry is 
 made into the intimate details of the history of the cases 
 I cannot think that my experience of this disease will 
 prove to be singular. In appendicitis perforation spells 
 purgation. 
 
 The facts that I have already stated show that the 
 indications for treatment at the onset of an acute inflam- 
 mation in the appendix are absolute starvation, so that all 
 peristaltic activity in the intestine is quieted, and the 
 bacterial virulence of the contents of the bowel greatly 
 reduced. The administration of fluids, which must reach
 
 EMERGENCIES OF ABDOMINAL DISEASE 1U9 
 
 the caecum to be absorbed, and the turbulent action and 
 the high bacterial malignity caused by an aperient are to 
 be avoided. It is in the caecum that bacteria are most 
 prolific and most virulent, and the vast increase in both 
 these qualities which comes from the giving of aperients 
 is especially to be avoided when the appendix, which 
 opens into the caecum, is inflamed. 
 
 The theme, then, which I desire to expound in this 
 connexion is that appendicitis is a disease which derives 
 its fiercest activities from the means which are taken to 
 treat it; that acute spreading peritonitis is rarely, if ever, 
 the result of an untreated disease, and that it is the 
 administration of aperients which transforms a simple 
 disease into one of the most serious type. Peritonitis so 
 arising is surely avoidable ; the catastrophe is the result of 
 misguided therapeutic activity. 
 
 I have come to the firm conclusion that, in spite of 
 the undoubted advantages which may in many cases 
 accrue from the starvation plan of treatment in acute 
 appendicitis, early or instant operation is always desir- 
 able. If the surgeon, when he is called in consultation, 
 hears that a purgative has been given, that alone should, 
 in my judgement, decide him to advise an immediate 
 operation. In children especially there must be no ex- 
 ceptions to this law. An acute attack in a child should 
 always be treated surgically, for the usual signs and 
 symptoms present in an adult are conspicuously lacking 
 here. I make, and admit, no exception to the rule that 
 in acute appendicitis in children urgent and early opera- 
 tion is essential. And by some means or another parents 
 should be made to know that the dosing of children with 
 aperients is an evil, and that they must put a check upon 
 those "philo-cathartic propensities" which seem insepar-
 
 150 ESSAYS ON SURGICAL SUBJECTS 
 
 able from motherhood. I would like to have the power 
 to write in every nursery in the world in large letters, 
 in the most prominent place, the two words, "Avoid 
 aperients." Or perhaps the warning and appeal might 
 be brought home a little more forcibly in an amended 
 edition of nursery rhymes: 
 
 Perforation means purgation 
 
 With the appendix kinked and bad; 
 Both food and drink will worry him, 
 
 And aperients drive him mad. 
 
 To give aperients to children who have a "stomach- 
 ache" is homicidal, yet so far as I can hear it hardly 
 occurs to a mother or nurse to do anything but this the 
 most disastrous thing of all. While I am speaking of this 
 let me say that the evidence now appears to me conclusive 
 that the "bilious attacks" of children, accompanied by 
 pain of a griping or colicky character, by vomiting, occa- 
 sionally by diarrhoea, by slight fever, and by headache, 
 and ascribed to the greedy indulgence in "indigestible" 
 foods, are nothing other than mild attacks of inflammation 
 in the appendix. When an attack more severe than all 
 the rest is plainly one needing operative treatment, and 
 the appendix is then removed, nothing is again heard of 
 the recurrent "bilious attacks." In these attacks, how- 
 ever, the appendix undergoes certain changes, for in my 
 experience it is rare to find in operating upon cases of 
 acute peritonitis, with gangrene or perforation of the 
 appendix, that this structure is free from adhesion or 
 obstruction. It is often difficult to deliver the caBcum 
 openly into the wound, because adhesion of the base of the 
 appendix about one inch from its attachment to the intes- 
 tine is so often found. I believe it therefore to be the rule, 
 both in children and in adults, that an acute attack
 
 EMERGENCIES OF ABDOMINAL DISEASE 151 
 
 of inflammation of the appendix arises in an organ 
 already diseased by reason of milder antecedent attacks, 
 that perforation and the spreading peritonitis which 
 it causes are almost invariably the result of the ad- 
 ministration of aperients, and are, accordingly, pre- 
 ventable complications. There is here only one safe 
 therapeutic rule, and it is "in all cases of abdominal 
 pain, avoid aperients." It cannot be denied that 
 in some cases of appendicitis in which the adminis- 
 tration of an aperient has caused a perforation there is a 
 history of one or many attacks having been relieved by 
 the remedy which on this occasion has led to dire disaster. 
 There is no difficulty in accepting and appreciating this 
 statement. For there is little doubt that the manifesta- 
 tions of appendicitis are often due to obstruction in the 
 lumen of this tube, and an aperient, by exciting an 
 increased activity of muscular contraction, may at one 
 time expel the obstructing material, and so give relief, and 
 at another time, being powerless to overcome the block, 
 may determine a rupture of the wall of the appendix at 
 or behind the point of difficulty. If the general experience 
 of others should coincide in these matters with my own, 
 the conclusion must be drawn that in a very large pro- 
 portion of the cases, probably I think in all, the serious 
 complications of appendicitis could be prevented by a 
 timely recognition of the disease, by absolute starvation 
 from the first moment of suspicion, and by the strict 
 avoidance of aperient medicines. But this state of per- 
 fection is not yet within sight, and we must accordingly be 
 on the watch for those earliest signals which indicate 
 that perforation has occurred and that peritonitis will be 
 swift to develop. The most significant of all indications 
 is indubitably abdominal rigidity. If a case of gangrenous
 
 152 ESSAYS ON SURGICAL SUBJECTS 
 
 appendicits is seen at the very earliest stage there will be 
 universal rigidity and immobility of the abdominal wall, 
 but the rigidity is appreciably greater on the side and over 
 the area of the lesion. The earliest case of acute gan- 
 grenous appendicitis I have seen was one to which I was 
 summoned by Mr. F. H. Mayo: 
 
 P., male, aged 36, on January 7th, 1909, had a sudden attack 
 of slight abdominal pain, which did not abate during the day. On 
 the morning of January 8th he was still suffering from an aching 
 pain and discomfort, and was unable to take his usual breakfast. 
 At 11 o'clock, as the bowels had not acted, he took an aperient, and 
 a little later a dose of Apenta water. During the afternoon he tried 
 to attend to business, but had to return home. At 7 p. M. he took 
 a little hot soup, and at 7.30 was seized with a most agonizing attack 
 of abdominal pain, which prostrated him. His father, hearing him 
 cry out, went upstairs to his room and found him lying on the floor, 
 unable to raise himself. Mr. Mayo saw him within a few minutes, 
 and I was in the house at 8.30 p. M. The patient was in great pain, 
 and was huddled up on a couch, the thighs flexed on the abdomen. 
 The pulse was 90; the abdomen was everywhere resistant, but 
 was intolerably sensitive over the right side. The abdomen was 
 opened in a nursing home between 9.30 and 10 p. M., and the ap- 
 pendix was found very much swollen and injected in its distal end. 
 The veins in the appendix and in the mesentery were thrombosed. 
 There was an obstruction in the lumen of the appendix about 1 in. 
 from the caecum. 
 
 This case showed that the sudden onset of thrombosis 
 of the vessels of the appendix, as of the vessels in the 
 enteric mesentery, is indicated by a sharp attack of 
 prostrating pain, and by the instant setting up of a 
 barrier of firmly contracted muscle, to act both as a 
 protection and a splint. 
 
 The sudden onset of acute intolerable pain and the 
 development of tense muscular rigidity in the whole 
 belly wall these two signs and these alone enable one
 
 EMERGENCIES OF ABDOMINAL DISEASE 153 
 
 to say that a serious lesion has occurred in the abdomen 
 which for its most certain relief will need the interven- 
 tion of the surgeon. A rapid pulse is never present, so 
 far as we know, within the first two or three hours; in 
 all the very early cases I have seen of perforation of any 
 viscus the pulse at first was under 90. The alteration in 
 its character and rapidity are, however, not long delayed, 
 and a steadily augmenting rate, the pulse adding a few 
 beats more hour by hour, is most significant. Nausea, 
 vomiting, and diarrhoea may all be present, but hardly 
 add anything of value to the other features of the dis- 
 ease. A strained and alert anxiety is noticed in the 
 expression, and the breathing is rapid and shallow, and 
 of the thoracic type. The diaphragm is as loath to move 
 as the other muscles with which it forms a wall around 
 the peritoneal cavity. It is, however, never held at first 
 in so firm a contraction in cases of perforative appen- 
 dicitis as in cases of rupture of the stomach or duodenum 
 or gall-bladder lesions which are, of course, in closest 
 proximity to it. This is another example of the fact 
 that muscular rigidity, though universal, is most strongly 
 developed in those parts which are most in need of rest 
 and protection. 
 
 The catastrophe which in point of frequency comes 
 next to appendicitis is concerned with the perforation of 
 an ulcer of the stomach or of the duodenum. Of these 
 ulcers there are, it is said, two types, the acute and the 
 chronic. The acute is probably toxaBmic in origin, and 
 appears when an infection, generally of an unusually 
 malignant character, is present in one part or another. 
 In the course of typhoid fever, in cases of burns and 
 scalds, in acute bullous pemphigus, in pneumonia, in cases 
 of septic infections following operations or independent of
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 them, and in erysipelas and the like disorders, an acute 
 ulceration of the stomach or of the duodenum, attended by 
 haemorrhage and perhaps proceeding to perforation, may 
 be found. The frequency with which these ulcers are 
 present in all periods of life is considerably underesti- 
 mated. For example, Helmholz, 1 by devoting his atten- 
 tion to the subject of duodenal ulcer in children, found in 
 six months as many examples as were contained in the 
 whole literature up to that time. In approximately 50 
 cases of perforating ulcer that I have had under my care, 
 once only has an acute ulcer been found. In the rest the 
 ulcer has been of the chronic type, and it has for months or 
 years declared its presence by the production and perpetu- 
 ation of symptoms as to whose significance no doubt ought 
 to have been felt. Not only does the ulcer which at last 
 ruptures into the general peritoneal cavity give clear and 
 sustained evidence of its presence, but in the few days or 
 weeks preceding the final rent it often declares its greater 
 activity and more pressing danger by a considerable exac- 
 erbation in the severity of the symptoms. 
 
 It is by degrees becoming more generally recognized 
 that chronic ulcers of the stomach and of the duodenum 
 are conditions that can be diagnosed with an approxima- 
 tion to accuracy which, though it leaves much to be 
 desired in the case of the former, is almost exact in the 
 case of the latter. And increasing confidence is being 
 displayed in the view, which some among us have long 
 expounded, that chronic ulcers are in all cases in need of 
 surgical treatment. We may accordingly have reasonable 
 expectations that with earlier and more confident diagnosis 
 and with a speedier resort to operative measures, the final 
 and often long-deferred catastrophe of perforation in a 
 chronic ulcer may be wholly avoided. Whenever a patient
 
 EMERGENCIES OF ABDOMINAL DISEASE 155 
 
 who has complained at intervals of indigestion begins to 
 suffer in the present attack more acutely than in an earlier 
 one, the signal of impending perforation is being raised 
 and the clear warning should by no means go unheeded. 
 
 At the moment when perforation occurs there is the 
 most agonizing and unendurable pain. Patients will 
 afterwards say that there is no pain so horrible in its 
 torture as this. The least movement seems to add some- 
 thing to its severity, so that a patient will perhaps remain 
 for hours almost without stirring. A medical man upon 
 whom I operated told me that the perforation had occurred 
 while he was crouched on his hands and knees in bed in a 
 position which seemed to relieve his pain. When the 
 rupture of the ulcer took place he could not move to reach 
 the bell, and had to wait motionless until help came to 
 him in the early morning. The tense rigidity of the 
 whole body is in striking contrast to the ceaseless un- 
 rest of a patient who is suffering the agony of hepatic 
 colic. In him a constant change of position and of pres- 
 sure seems in some measure to cause abatement of the 
 pain, or, at least, to be imposed upon the patient in the 
 search for relief that never comes. The abdominal 
 muscles are found to be in a condition of inflexible rigidity, 
 but even here some difference in the various parts of the 
 abdomen can be felt. Over the ulcer the stiffness is of 
 the most obdurate character; one might almost think that 
 a disc of metal replaced the supple muscle. This local 
 increase of a general resistance is most definite and dis- 
 tinct, as a rule, and it affords a decided help not only in 
 the diagnosis of the lesion but in its location. The 
 patient's expression is of one who is terror-struck. The 
 approach of a hand to the abdomen for the purposes of 
 examination is quickly resented, and the most piteous
 
 156 ESSAYS ON SURGICAL SUBJECTS 
 
 appeal for gentleness is made. The breathing is short, 
 jerky, and shallow, and the patient may indeed cry out 
 that he "cannot breathe." This is due in part no doubt 
 to a spasm of the diaphragm, and in part also, I believe, 
 to that great overdistension of the stomach which is so 
 commonly seen when the abdomen is opened. Though 
 the patient looks generally ill with pallid face, staring 
 eyes, and sweating brow the pulse will be found at the 
 first to be hardly altered in frequency or in volume. This 
 is one of the surprises which must not fail to be recog- 
 nized and remembered. I have often been told by medi- 
 cal men that at the first view of a case they could hardly 
 bring themselves to believe in the occurrence of a perfora- 
 tion, since the pulse was so tranquil and full; and in a 
 case I saw some years ago with Dr. Carlton Oldfield, we 
 deliberately postponed for a few hours any question of 
 operative treatment because the pulse, in rate and volume, 
 was normal. Unhappily, this fact of the unaltered pulse- 
 rate is even now not generally recognized; accordingly 
 delay, which is always serious, may occur. The pulse 
 increases in frequency and depreciates in value very soon, 
 but this is due not to the perforation but to the peritoneal 
 contamination which is the inevitable sequel. No one 
 has any difficulty in recognizing the presence of perito- 
 nitis, but our aim must always be to discover at the 
 moment of its occurrence the lesion to which the peri- 
 toneal infection is secondary. The symptoms and the 
 signs of the perforation of a hollow viscus are not those of 
 the peritonitis, which make haste to develop. 
 
 Among the catastrophes to which attention has been 
 especially directed within recent years, the most remark- 
 able, from many points of view, is that which involves the 
 pancreas in an acute inflammation. For some time after
 
 EMERGENCIES OF ABDOMINAL DISEASE 157 
 
 the remarkable paper by Dr. Fitz in 1889, the condition 
 of "acute haemorrhagic pancreatitis" was believed to be 
 of great rarity; but, as in so many other cases, the recent 
 investigations of the surgeon have shown that infrequency 
 of occurrence meant inadequacy of observation. I have 
 operated upon 11 cases of the most acute kind, and 
 7 patients (the last 6 in succession) have recovered. Of 
 the less acute cases which pass over the initial stage, to 
 be operated upon some days or weeks later, I have had 
 several more. 
 
 The onset of pain in acute pancreatitis is usually sud- 
 den; a moment before the patient may have been going 
 about in comfort, conducting the ordinary affairs of the 
 day. The absolutely instantaneous onset of the very 
 severe pain is constant, but some of the patients will say 
 that they have been conscious for a few hours, or it may be 
 for a few days, of a sense of discomfort or milder pain in the 
 upper part of the abdomen. About one-third of the total 
 number of observed cases have occurred in patients who 
 were the subject of recurring flatulent dyspepsia. The 
 patients are generally stout; women are affected slightly 
 more than men, and pregnancy would seem to be a factor 
 of some importance in the causation. The intense pain, 
 then, is sudden in onset, is confined within the abdomen to 
 the upper portion, but passes almost always through to the 
 back; it is agonizing beyond endurance, and is not seldom 
 the cause of fainting or a profound collapse. The face is 
 drawn and white, though the lips are often blue. In 
 many of the cases I have seen there has been a curious 
 leaden colour of the whole face, a slight but unmistakable 
 and I think characteristic cyanosis. Halsted, an early and 
 shrewd investigator, pointed out that lividity of the face 
 and abdominal wall was often a striking feature of these
 
 158 ESSAYS ON SURGICAL SUBJECTS 
 
 cases. The whole appearance and attitude of the patient 
 suggest that death may be imminent, for the extremities 
 are cold, the heart beats with great rapidity, and the 
 quality of the pulse is poor. Vomiting is an early symp- 
 tom, is frequently repeated, and may last for days or 
 weeks if the patient should survive so long. The food 
 that has last been taken is the first to be ejected; after- 
 wards all the vomited matters are deeply stained with 
 bile, and pure bile, to all appearance, may be brought up 
 in large quantities. This has suggested in several cases 
 a diagnosis of high obstruction in the jejunum. The 
 patient, as will be grasped from this description, presents 
 the aspect and the symptoms of profound poisoning; and 
 the researches of Gulecke, Egdahl, and others make it 
 appear probable that the toxic substances are produced 
 as a result of the digestion of the pancreas by its own 
 escaped secretions. The abdomen, when examined early, 
 presents the most indomitable rigidity and some fulness 
 in the upper part; the remaining parts may be quite soft 
 and flaccid, yielding readily to the hand, or they may be 
 held with some degree of firmness. The upper portion 
 of the abdomen, the epigastric region especially, never 
 ceases to offer the most incoercible resistance, and, how- 
 ever gentle the examination may be, it is grievously 
 resented and is repelled at the earliest occasion. When 
 the records of published cases of acute pancreatitis are 
 studied, it is seen that the number that have been cor- 
 rectly diagnosed before the operation is extremely small; 
 yet I am confident that the symptoms are of such a 
 character as to make a recognition of their cause a 
 matter of very little difficulty. Briefly to recapitulate, 
 there is, perhaps, in a patient inclined to stoutness a 
 history of antecedent dyspepsia which presents nothing
 
 EMERGENCIES OF ABDOMINAL DISEASE 159 
 
 of the characteristic features of duodenal or, indeed, of 
 gastric ulceration, but which suggests rather the presence 
 of stones in the gall-bladder, and jaundice may have 
 been noticed on one or many occasions. The severe 
 pain comes quite suddenly, is beyond the limits of human 
 fortitude to withstand, is associated with collapse of 
 a profound character, and may cause the patient to 
 swoon. The limbs are cold, the pulse extremely poor, 
 rapid, and thin, or even hardly to be felt and not to 
 be counted. The face may be cyanosed. The upper 
 part of the abdomen is exquisitely tender, and all the 
 muscles there offer the most resolute resistance to any 
 examination. Vomiting is an early and often a con- 
 spicuous feature. I do not think a group of symptoms 
 at all similar is to be found in any other form of ab- 
 dominal calamity. There can be no doubt that, as 
 in the case of perforations of the stomach or duodenum, 
 recovery may follow an attack of acute pancreatitis. 
 Every now and again I find the evidence of this in the 
 abdomen. Very extensive fat necrosis in or upon the 
 pancreas, and in its immediate vicinity, is to be seen, and 
 the pancreas itself may show the remnants of old haemor- 
 rhages or contain a cyst, an abscess, or a slough. But 
 these occasional survivals cannot impugn the fact that the 
 safest course here also lies in early operation upon the 
 lines first followed by Dr. Ramsay of Bournemouth. I 
 have recently operated upon a case of acute pancreatitis 
 with Dr. Macklin of Whalley, who had the fortunate 
 opportunity of seeing the patient within a few minutes of 
 the onset of the severe pain. He has kindly written for me 
 the following very graphic account: 
 
 The patient was a lady, aged 54, of stout build. When sum- 
 moned to her, about 3 P. M. on December 7th, 1910, I found the
 
 160 ESSAYS ON SURGICAL SUBJECTS 
 
 patient verging on collapse, suffering great pain, and vomiting 
 freely. The vomit was evidently partially digested food of which 
 she had partaken very heartily an hour or two before. There 
 was no relief from the vomiting, and the pain was aggravated on 
 assuming the recumbent position, which I induced her to adopt, 
 and almost immediately she had to resume the semirecumbent posi- 
 tion in which I had found her. From the first the pulse was very 
 rapid and very faint and the respiration very shallow and sighing. 
 In about a quarter of an hour or so she became almost pulseless, 
 the features very pinched and pale, although there was a suggestion of 
 cyanosis in her appearance. At this point ether was injected hypo- 
 dermically, as she appeared to be about to die. The effect of this 
 was seen very quickly as the pulse began to improve and the col- 
 our to return to her face. Soon after I had the patient removed to 
 a couch, but she could not assume the recumbent position with- 
 out aggravating the pain, which had begun to abate in some degree 
 by the time. In the meantime the vomiting had diminished in 
 frequency and profuseness, although from time to time a small 
 quantity of fluid came up which was mostly water (of which she 
 drank from time to time) stained with bile. Previous to my arrival 
 the patient had had brandy, and some more was given by my in- 
 structions during my brief temporary absence to procure the ether. 
 About two hours after the beginning of the attack she was removed 
 home, less than a mile off, by motor and put to bed, which had 
 previously been prepared for her reception. On examining the ab- 
 domen there was some considerable distension generally found, but 
 more pronounced in the epigastric region, where there was great 
 tenderness, so much so that the patient could hardly bear the slightest 
 attempt at pressure. The lower part of the abdomen was very 
 flaccid and not at all tender. Pain continued very severe and vomit- 
 ing continued more or less frequently, but in all very small quantities. 
 The pulse became very irregular and weak after the temporary 
 increase during which she was removed home. The degree of prostra- 
 tion continued so great that I considered it advisable to inject an 
 ounce of brandy per rectum from time to time during the night. 
 About 1 A. M . I left her, as the severity of the symptoms had abated 
 somewhat and the pulse had become more regular and stronger, but I 
 felt it safer to leave a hypodermic with ether and strychnine with
 
 EMERGENCIES OF ABDOMINAL DISEASE 161 
 
 the nurse in case of emergency. At 9 on Thursday, the 8th, I found 
 the patient still complaining of much pain and still vomiting at 
 intervals, but otherwise better, wherefore I injected grain of 
 morphine, which induced after a short time a few hours' sleep. 
 Towards nightfall the patient began to complain of pain again, but 
 more of a dull aching character, which was felt almost entirely 
 to the left side, passing through to the back and shoulders. There 
 was less tenderness on palpation, the abdomen was still tense, 
 but no peritonitis was present; vomiting recurred, similar in character, 
 but small in quantity. Towards Friday morning, the 9th, the char- 
 acter of the vomit changed, and it became more abundant in quantity. 
 The vomit consisted of a dark green looking fluid which had a sug- 
 gestion of "coffee grounds" about it. 
 
 At the operation we found wide-spread fat necrosis, 
 especially in the upper part of Morison's pouch on the 
 right side, an enormous enlargement of the pancreas, 
 which was like a phlegmon, and a deep purple engorge- 
 ment of the gall-bladder. Cholecystotomy was performed, 
 and thick black bile drained from the tube for two weeks; 
 two drains of rubber tissue were also passed down to the 
 pancreas. The patient made a most excellent recovery. 
 
 So far as my own experience goes, the only other 
 abdominal emergency in which there occurs a profound 
 collapse, with instant lowering of the blood-pressure and 
 a general depression of the circulation, is dependent upon 
 the rupture of a tubal gestation. But in a number of 
 cases of this condition which I have treated I have only 
 once felt any slightest doubt as to the diagnosis, and that 
 was in a case which occurred twenty years ago, at a time 
 when the diagnosis of abdominal diseases could not be 
 made with that confidence and accuracy which we possess 
 to-day. The history in cases of ruptured tubal pregnancy 
 is characteristic. The patient is generally between the 
 
 ages of 20 and 40, and one menstrual period has been 
 a
 
 162 ESSAYS ON SURGICAL SUBJECTS 
 
 missed. About two or three weeks after the time at which 
 the period should have occurred (sometimes, though 
 rarely, even later than this; in one of my cases over ten 
 weeks after) there is a slight vaginal discharge of blood, 
 and almost at the same time an attack of severe abdom- 
 inal pain, followed very speedily by pallor, faintness, col- 
 lapse, air-hunger, sighing, restlessness, and all the symp- 
 toms of great loss of blood. The pain is acute, but does 
 not even remotely approach in intensity that which is 
 present in the conditions I have already described. The 
 patients, indeed, usually say that they feel as if "some- 
 thing had given way" or as if "something had burst" 
 within the body. The abdomen becomes full, especially 
 in its lower half, where a feeling of tumidity, of "doughi- 
 ness," is often present; and occasionally one side is more 
 tender than the other. Resistance to the examining hand 
 is not present. The muscles, it is true, may be in some 
 degrees tightened by reason of the sudden increase in the 
 contents of the abdomen, but the stubborn and unchang- 
 ing muscular rigidity of the other catastrophes is never 
 present in this. In a few of my cases there has been, as it 
 were, a miniature attack of this kind before the formidable 
 and final seizure has come ; such are due, no doubt, to little 
 leakings from a tiny rent, whose edges are presently 
 torn widely asunder to give vent to the profuse bleeding 
 which is taking place. It is, I think, quite impossible 
 for any one now to mistake this clinical picture for 
 any other; the correct diagnosis should always be easily 
 possible. 
 
 The crises that develop in the course of cholelithiasis 
 are exceedingly few. In more than two thousand gall- 
 stone cases I have only twice met with a sudden rupture 
 of the gall-bladder, only thrice with acute phlegmonous
 
 EMERGENCIES OF ABDOMINAL DISEASE 163 
 
 cholecystitis, and only once with acute gangrene with per- 
 foration of a common bile-duct, which was completely oc- 
 cluded by a large stone. The attacks of hepatic colic, es- 
 pecially those which are due to the temporary impaction 
 of a calculus in the cystic duct, are terrific in severity, but 
 they are not lethal; the agony is almost unendurable 
 while it lasts, and the very extremity of endurance is 
 reached, but the danger to life is quite inconsiderable. 
 The acute cholecystitis which results will almost without 
 exception subside in the course of a few days, so that a 
 deliberate operation can then be undertaken with every 
 circumstance of care. That which chiefly distinguishes a 
 patient suffering the torture of colic, whether hepatic, 
 renal, or intestinal, from one in whom the perforation of a 
 hollow viscus has occurred, is his ceaseless agitation and 
 unrest. The former patient tosses and throws himself 
 about, writhes on the floor or the bed, doubles and twists 
 himself in the constant effort to get ease ; the latter at the 
 moment of the catastrophe seems to be struck motionless, 
 and for hours may be hardly able to breathe or stir. How- 
 ever acute the torment of hepatic colic, there does not seem 
 to be any rigidity of the abdomen except in the immediate 
 region of the gall-bladder. All other parts are supple and 
 free from any tenderness. A rigor, or a brief shudder, 
 with only a trivial increase of temperature, is seen not 
 infrequently in cases of incipient cholecystitis. When per- 
 foration takes place the temperature always falls. In all 
 my hospital experience I have only known one case of 
 hepatic colic sent in as a case of perforated gastric ulcer, 
 and in that case there was also a subacute pancreatitis, 
 for when an operation was undertaken some days later 
 recent evidences of fat necrosis were to be seen. 
 
 Whenever the surgeon is called to see a patient who is
 
 164 ESSAYS ON SURGICAL SUBJECTS 
 
 believed to be suffering from an acute abdominal catas- 
 trophe he must bear in mind the possibility of the mimicry 
 of this condition by a lesion above the diaphragm, an 
 acute pneumonia, an acute basal pleurisy, or an acute 
 pericarditis. In all these diseases in their earliest stage 
 there may be severe pain, and some rigidity of the 
 abdomen, more especially in the upper parts, and the 
 resemblance to the conditions in an acute abdominal 
 disease may be very close. In thoracic diseases the res- 
 pirations are quickened out of all proportion to the rapid- 
 ity of the pulse rate. If the respirations are more frequent 
 than one-third of the pulse rate, a pulmonary lesion should 
 always be suspected. In thoracic diseases there is almost 
 always some elevation of temperature ; in abdominal catas- 
 trophes there may be a normal or subnormal temperature. 
 In the acute abdominal conditions already described the 
 rigidity of the abdominal muscles is of the most extreme 
 degree ; in the thoracic conditions there may be stiffness, 
 which is superficial and readily overcome ; there is little 
 or no tenderness, and often much relief from a degree of 
 pressure, which if the abdomen were affected would be 
 quite unbearable. 
 
 These are the chief among the various and most serious 
 forms of calamity that occur in connexion with diseases of 
 the abdominal viscera. Of all such it is true to say that 
 they should rarely be allowed to occur. We are now able 
 to recognize with rapidly increasing accuracy the correct 
 interpretation of many symptoms formerly ascribed to 
 "functional" causes. We are quickly being brought to 
 realize that those recurring symptoms formerly supposed 
 to indicate some vice in the action, some change in the 
 secretion, or some disorder in the sensation of an abdom- 
 inal organ, are in reality due to a perceptible alteration in
 
 EMERGENCIES OF ABDOMINAL DISEASE 165 
 
 its structure, and that though medical treatment and con- 
 tinued watchful care may allay for a longer or a shorter 
 time the symptoms which such organic diseases arouse, 
 surgical treatment alone is capable of giving complete 
 and lasting relief. And so it would appear certain that 
 by efficient treatment of the chronic disorder the acute 
 emergency for which it is surely responsible will be 
 forestalled. Yet still the need remains, not only that we 
 should learn to evade the catastrophe whenever possible, 
 but also that we should recognize with fullest accuracy all 
 those manifestations which swiftly develop when once the 
 crisis has occurred. We must free ourselves from the 
 tyranny of the text-book, which still chiefly deals with 
 terminal events, and make certain that we know the 
 essential difference between the signs and symptoms of 
 the primary catastrophe and those of the various compli- 
 cations which finally develop. We must have a concep- 
 tion of abdominal diseases which is radically wrong if we do 
 not realize that the exigencies which spring up so quickly 
 and prove so serious are each one of them a very heavy 
 rebuke both to our power of early diagnosis and to the 
 resources of medical and dietetic treatment. 
 
 CONCLUSIONS 
 
 What, then, are the conclusions of the whole matter 
 that we are entitled to draw? They are, I think, as 
 follows: 
 
 1. The catastrophes which occur within the abdomen 
 are not, strictly speaking, "acute"; they are, on the con- 
 trary, usually the result of the abrupt transition from a 
 quiescent to an acute phase in a disorder of long standing. 
 
 2. An acute emergency can, therefore, be prevented by 
 a timely recognition of the value and the significance of
 
 166 ESSAYS ON SURGICAL SUBJECTS 
 
 the early symptoms, so often ignored or misunderstood, of 
 the chronic malady in which it is the final development. 
 
 3. The occurrence of a sudden attack of intolerable 
 agony in the abdomen, associated with tense rigidity of 
 all the abdominal muscles, indicates that there is an acute 
 lesion which needs immediate surgical attention. These 
 two signs, and these alone, are an urgent warrant and 
 compulsion to us to treat the case at once by operation. 
 
 4. A different diagnosis is generally possible if strict 
 attention be paid to the details of the anamnesis, and if 
 the firm abdominal wall be searched for a tender area of 
 supreme resistance. 
 
 5. The perforation of a hollow viscus is indicated by 
 the rigid immobility of the patient. Colic causes ceaseless 
 unrest. 
 
 6. Shock is not a symptom of perforation, for in the 
 early hours after this disaster has occurred the pulse is 
 very little altered in volume or in rate. 
 
 7. In all cases of abdominal pain, especially in children, 
 the use of aperients should be avoided. 
 
 REFERENCE. 
 1 Archives of Pediatrics, September, 1909.
 
 THE GIFTS OF SURGERY TO MEDICINE 
 
 The annual address in surgery delivered before the 
 British Medical Association: 
 
 MR. PRESIDENT, LADIES, AND GENTLEMEN: The 
 choice of the title for the address which I have the high 
 honour to deliver must not lightly be held to indicate that 
 I admit any difference between the essentials of medicine 
 and surgery. The two sciences or arts are not in the re- 
 motest particular antagonistic ; rather is it true to say that 
 they are indeed one and indivisible, and that the separa- 
 tion between the two aspects which are presented to us is 
 due to the limitations of the human intellect alone. It has 
 been too long the custom for surgery to be divorced from 
 medicine, for the problems of mind and of hand to be con- 
 sidered as distinct from one another. Happily, owing to 
 the work which has been done in recent years, opportuni- 
 ties have abundantly been afforded for demonstrating the 
 power of surgical research to enlarge the scope and to en- 
 rich the knowledge of many of the problems of internal 
 medicine. By a study of what I have ventured to call the 
 "pathology of the living" a very profound change has by 
 degrees crept over our knowledge of almost every form of 
 chronic abdominal disorder. 
 
 POST-MORTEM ROOM STATISTICS 
 
 In the earlier years of the nineteenth century an ac- 
 quaintance with the morbid processes attacking internal 
 organs was based upon two sources of information only 
 upon an inquiry into the details of the clinical history of 
 
 Reprinted from The British Medical Journal, July 26, 1913. 
 167
 
 168 ESSAYS ON SURGICAL SUBJECTS 
 
 any disease as it developed, waned, or progressed, and 
 upon the examination of the parts involved after the death 
 of the sufferer. 
 
 I have endeavoured to show, on more than one occa- 
 sion, how impossible it is to measure the sufferings of 
 patients during their lives, or to assess their chances of 
 death from any disease, by a consideration of the statistics 
 gathered from the post-mortem room experience. People 
 do not die in hospital from the chronic diseases from which 
 they suffer during life. It is, so far as the surgical side is 
 concerned, the acute terminal infections, malignant disease 
 in all its forms, especially those lending themselves to sur- 
 gical consideration, and the accidents of civil life, that 
 supply the bulk of the material upon which the pathologist 
 makes his observations. The statistics of Brinton and 
 Welch, for example, two of the very ablest men ever en- 
 gaged in medical work, upon gastric ulcer statistics that 
 meet one at every turn of the page in the literature of this 
 subject are, in my view, almost without value. For the 
 observations were not made entirely by themselves alone, 
 but by a number of observers of differing capacity working 
 in distant places under diverse conditions. There could 
 be, therefore, no common denominator ; there was nothing 
 by which the values of recorded figures could be made 
 equal. And it would be futile to suppose that the patients 
 who suffer from duodenal or gastric ulcer during life are 
 adequately represented, in point of number, by those who 
 die from these conditions in the wards of a hospital, or by 
 those in whose bodies the traces of old, and perhaps quite 
 inconspicuous, scarring or ulceration are discovered. We 
 shall not, I hope, hear much in the future of post-mortem 
 statistics as the guides or dictators of our opinions as to the 
 maladies of the h'ving.
 
 THE GIFTS OF SURGERY TO MEDICINE i69 
 
 THE SURGEON'S POSSIBILITIES OF DIAGNOSIS IN THE 
 
 LIVING 
 
 When the great gift of America to humanity the dis- 
 covery of the anaesthetic power of ether was brought to 
 the aid of the operator, vast possibilities were at once 
 apparent in the range of the surgeon's work. But the 
 dread of infection indeed, the certainty of infection 
 held his hand for more than a generation, till the work of 
 the greatest man our profession has ever produced, Lister, 
 made the dream of the surgeon come true, made it possible 
 for him with safety to carry through many procedures 
 which before had been impossible. More than this, the 
 chance was given to undertake the treatment of diseases 
 which had formerly run their hasty or lingering course un- 
 checked. Little by little our scope then widened. Acute 
 conditions were at first attacked, perforations of the hollow 
 viscera, gangrene of the appendix, haemorrhages from the 
 bursting of a tubal gestation, and so forth. By degrees the 
 impression grew that such acute catastrophes were but 
 final stages, terminal events in the history of diseases whose 
 presence and course were betrayed by symptoms which 
 were clear and often characteristic. When these condi- 
 tions were approached surgically in their earlier and more 
 quiescent periods the results of operations were at first 
 not very satisfactory. Crude methods and imperfect 
 technique left legacies of trouble behind them. The 
 mortality was high, and remote results w r ere rarely ideal. 
 
 It is interesting now to recall the clumsy manifesta- 
 tions which attended such operations as cholecystostomy 
 or gastro-enterostomy in the days of their infancy. Owing 
 to the labours of Senn and of Murphy simpler methods 
 began to find a place. The bone-plates and the button
 
 170 ESSAYS ON SURGICAL SUBJECTS 
 
 showed how little was really necessary to secure firm and 
 permanent union between well-clad peritoneal surfaces. 
 Though these instruments are now discarded entirely, to 
 all of us the lessons learnt from them were most important 
 and most necessary. But for them we should never have 
 realised as we do to-day how speedily and how simply 
 those manipulations can be carried through with precision 
 which before had occupied two or three hours and had 
 involved the separate introduction of 200 or 300 stitches. 
 In surgery complexity of procedure indicates defect in 
 method. The search in all our w r ork is for the simple 
 way. In surgery, as in other arts, simplicity is the supreme 
 virtue. Our unceasing efforts in technique are to discover 
 what may safely be left out. 
 
 THE ASSOCIATION OF ABDOMINAL DISEASES POINTING 
 TO A COMMON CAUSE 
 
 As we began to recognize, almost unconsciously, the 
 ease and sufficiency of the simple mode, the mortality from 
 all operations fell rapidly. So it became a safe and cus- 
 tomary procedure not only to deal with the particular 
 lesion which had demanded attention but also to inves- 
 tigate the conditions of adjacent organs. And there sur- 
 prising developments awaited the inquirer and rewarded 
 his eager search. Conditions other than those which 
 needed immediate attention were found to exist with no 
 little frequency. In diseases of the stomach or duodenum 
 the gall-bladder was found not seldom implicated also; in 
 diseases of the latter, as of the former, the vermiform ap- 
 pendix seemed often to play the part of an infecting agent. 
 And so by slow degrees the conviction was borne in upon 
 us that these diseases I have named did not stand in rigid 
 isolation, one separate entirely from the other, but that
 
 THE GIFTS OF SURGERY TO MEDICINE 171 
 
 their association was so frequent as to indicate the strong 
 probability of some underlying primary cause. Infection, 
 it was soon asserted, whether carried by the blood-stream, 
 by the lymphatics, or ascending, as Bond has shown with 
 great clearness, along the mucous canals, was the prime 
 evil. Differences of opinion were soon declared, and still 
 continue, as to the source of the infection. To many of 
 us the quiescent inflammatory lesions of the appendix 
 seem the most potent and the most persistent of all. 
 Arbuthnot Lane, as I shall presently state more fully, 
 holds firmly to the belief that the infections for the diseases 
 I have named, as of many others, have their origin in the 
 intestine, large or small. And his views are sustained by 
 him with quiet and characteristic courage, and with a 
 record of results that compel attention even from the most 
 sceptical. 
 
 A DEBT OF SURGERY 
 
 To the surgical assault we made upon our patients 
 for the purposes of this study of the "pathology of the 
 living" there was one serious objection. After all abdom- 
 inal operations some pain was felt. Not very much in the 
 ordinary appendix cases, a little more perhaps in the gastric 
 cases, and certainly more in the patients who had sub- 
 mitted to operations upon the biliary tract. The pain was 
 rarely very severe, but it called often for the administra- 
 tion of a small dose of morphine, and it was certainly 
 enough to constitute a blemish upon our artistry. Fur- 
 ther than this, it was noticed that after an operation in- 
 volving a handling of the parietal peritoneum, even so 
 slight a manipulation as the separation and ligature of a 
 hernial sac, the patient complained of flatulence, which, in 
 the more severe cases of abdominal exploration and hand- 
 ling, was severe and most distressing. It had long ap-
 
 172 ESSAYS ON SURGICAL SUBJECTS 
 
 peared quite certain to me that the condition described 
 by the patient as "flatulence," the "gas pains" of the 
 American surgeon, had really little or nothing to do with 
 gaseous distension of the intestines. There was a feeling 
 of "fullness" to the patient; but often no recognisable in- 
 flation of the intestines when an examination was made, 
 nor was any real relief obtained by the expulsion of gas. 
 Flatulence, I felt convinced, was the name given to a con- 
 dition which depended upon trauma, or the rough handling 
 of the parts engaged in the operation. Happily we are 
 now able to make certain that any operative procedure in 
 the abdomen can be carried out thoroughly without the 
 infliction upon the patient of any intolerable pain and 
 without his being caused to suffer severe flatulent distress 
 afterwards. 
 
 ANOCI-ASSOCIATION 
 
 Crile has enunciated the principle of "anoci-associa- 
 tion." He has shown that in the condition recognised as 
 "shock" definite and demonstrable changes occur in the 
 cells of the brain, which have discharged all the energy 
 they had stored. This exhausting discharge of nervous 
 energy is due to that excitation which is caused by the 
 infliction of numberless injuries, each of them small, or to 
 the infliction of one overwhelming impression. When an 
 operation is performed under ether anaesthesia, the opera- 
 tor may delude himself into the belief that because his 
 patient lies unconscious, and apparently unresponsive to 
 any hurt, therefore no damage to his nerve centres is pos- 
 sible. But ether anaesthesia does not put all the brain to 
 sleep; the larger part, and by far the more important part, 
 is awake and staring, ready to be acted upon, and to be 
 injured, just as easily as if the patient were awake. The 
 fact that some operators produce little constitutional dis-
 
 THE GIFTS OF SURGERY TO MEDICINE 173 
 
 turbance, little shock, by the performance of an operation 
 which at the hands of another causes very serious collapse, 
 is not due to differences in the patient, in the anaesthetist, 
 in the method, or in anything else but the surgeon himself. 
 There are surgeons who operate upon the "canine" prin- 
 ciple of savage attack, and the biting and the tearing of 
 tissues are terrible to witness. These are they who oper- 
 ate with one eye upon the clock, and who judge of the 
 beauty of any procedure by the fewness of the minutes 
 which it has taken to complete. There are other surgeons 
 who believe in the "light hand," who use the utmost gentle- 
 ness, and who deal lovingly with every tissue that they 
 touch. The former type of operator is described by Crile 
 as "carnivorous"; the latter type is nowhere better ex- 
 hibited than in his own work. The scalpel is, indeed, an 
 instrument of most precious use in some hands a royal 
 sceptre; in others but a rude mattock. The perfect sur- 
 geon must have the "heart of a lion and the hand of a lady" ; 
 never the claws of a lion and the heart of a sheep. 
 
 The brain, then, under ether anaesthesia is in great part 
 wide awake, appreciative of stimuli, and in part responsive 
 to them. During any surgical operation, Crile assures us, 
 there is, in reply to every incision, every pull of the re- 
 tractors, indeed to every physical contact, a change in the 
 pulse, the respiration, and the blood-pressure. Every 
 surgeon conversant with abdominal work knows how a 
 rough handling will cause tension in the muscles and 
 deepen the patient's breathing, making loud and stridulous 
 the expiratory effort, as though the victim were groaning 
 in his agony. No general anaesthetic, it is clear, can 
 shelter the brain from the assault committed upon it by 
 the injuries inflicted during an operation. Crile has 
 therefore suggested that by means of local anaesthetics
 
 ITU ESSAYS ON SURGICAL SUBJECTS 
 
 novocaine for the skin, quinine and urea for the parietal 
 peritoneum a barrier can be erected around the area to be 
 operated upon, so that no nerve impulses can be conveyed 
 from the territory so isolated. The field of operation, that 
 is to say, may be temporarily disconnected from the brain, 
 not only at the time of operation, but for periods of one to 
 five days subsequently. The operation then is conducted 
 in an area which, for the time being, does not belong to 
 the patient, which he cannot reach by any impulse di- 
 rected towards it, and which can be dealt with as the 
 surgeon wishes without the patient having any power of 
 receiving impressions from it. 1 
 
 But this is not all. Shock may be produced not only 
 by physical violence, but also by psychical disturbances, 
 by emotional excitement, by the receipt, for example, of 
 good or bad news or by fear, the suspense and the trials of 
 some great ordeal. By many patients their submission to 
 an operation is viewed with dread and apprehension. In 
 order that the best results should follow upon our work it is 
 necessary that every consideration should be shown to a 
 patient, and every proper regard to his wishes; every 
 encouragement should be offered, and the impression 
 forced upon him that all those engaged in the operation or 
 his after-treatment are working strenuously to the one end 
 his assured and rapid recovery. The fears which hover 
 round the last hour before an operation are greatly modi- 
 fied by the administration of a small dose of morphine 
 with scopolamine. A happy frame of mind is thereby 
 induced, and very little nitrous oxide gas is required to 
 put the patient soundly to sleep. The memory of the 
 conveyance of the patient to the operation theatre and of 
 the administration of the anaesthetic is often abolished by 
 
 1 The Lancet, July 5, 1913, p. 7.
 
 THE GIFTS OF SURGERY TO MEDICINE 175 
 
 these measures. This is, in brief, the method of Crile, 
 which I have used for many months, and which has added 
 a pleasure to my work that is really immeasurable. To 
 the great discoveries of Morton and of Lister this of Crile 
 seems to be the fitting completion. 
 
 Several interesting side issues have developed as this 
 procedure has become more widely practised. The most 
 striking of all improved results is seen in the treatment of 
 exophthalmic goitre. In England we see little of this 
 disease, and very few operations appear to be necessary. 
 In America, where the days are more strenuous and the 
 rush of life more eager, operations are more often and 
 more urgently needed. After such operations it was no 
 uncommon thing to find that the patient suffered pro- 
 foundly from "shock," and the heart beat so rapidly that 
 it often seemed to be galloping to death. After an opera- 
 tion conducted by Crile's method the emotional activities 
 of the patient are undisturbed, and within a few days his 
 whole appearance and condition undergo a striking change 
 for the better. "Aseptic wound fever" is almost certainly 
 due to psychical factors. 
 
 EARLY SYMPTOMS AND LATE SIGNS 
 
 Equipped with these new powers, due to the three dis- 
 coveries of ether, 1 of antisepsis, and of anoci-association, 
 the surgeon has been empowered to conduct his investiga- 
 tions into the conditions of disease in an entirely novel 
 manner. Half a century ago a patient who was suffering 
 from any form of abdominal disorder could not do more 
 than describe his symptoms in detail to his medical 
 attendant. He could not lend his body to inquiry, and no 
 
 1 1 say nothing of chloroform, for I dislike and fear it intensely and use it 
 hardly at all.
 
 176 ESSAYS ON SURGICAL SUBJECTS 
 
 investigation of the parts concerned in his disorder could 
 be conducted until after death. Death might occur from 
 the final stages of this same disease, or more often from 
 some intercurrent and independent malady. It was diffi- 
 cult then for the pathologist conducting an examination of 
 the body to make the symptoms and the signs tally, for 
 at this stage they had probably ceased to correspond one 
 to another. The final ruin of an abbey tells us nothing of 
 the domestic habits of the monks who found shelter 
 within its once unbroken walls. The ultimate devasta- 
 tion in a lesion of the stomach, such as is seen on the 
 necropsy table, tells us nothing of any value of those 
 early wanderings from the normal condition which the 
 same parts had once displayed. Terminal events may seem 
 to have no connexion, or at best a very remote one, with 
 the early changes of which they are the outcome. All the 
 knowledge our forefathers possessed of the power of or- 
 ganic changes to cause clinical symptoms depended upon 
 an inquiry into those changes when they had reached the 
 last stage in their career. This last stage might be disas- 
 trous, as in the case of a chronic ulcer of the stomach which 
 had led to cancer; or it might be inconspicuous, as in 
 the case of a duodenal ulcer which had healed, as such 
 ulcers sometimes will, without leaving any scar, or only 
 such as the pathologist in his haste may overlook. So 
 all was confusion. Two incompatible things were con- 
 sidered side by side early symptoms and late signs. 
 When we consider the crushing disadvantages under 
 which our forefathers worked it is amazing to find how 
 much they did, and with what accuracy they had solved 
 many problems. The most conspicuous example of this 
 extraordinary insight into abdominal diseases is, I think, 
 afforded by the work of Brinton, whose books on "Diseases
 
 THE GIFTS OF SURGERY TO MEDICINE 177 
 
 of the Stomach" and on "Ulcer of the Stomach" for wide 
 observation, profound and cogent reasoning, and beauty of 
 language have never been challenged by those of any other 
 writers. But with the new methods to which I have re- 
 ferred the study of the pathology of the living became 
 possible. Symptoms recited at the moment could be 
 ascribed to the lesion disclosed by the operation in the 
 precise stage of its existence in which it was capable of 
 arousing those symptoms. The history of abdominal 
 surgery in the last ten years is the tale of the lessons that 
 were learnt. 
 
 The most considerable revolution has occurred in con- 
 nexion with our inquiry into the condition of "dyspepsia." 
 To any who have no acquaintance with their works I can 
 hardly imagine a greater intellectual delight than to read 
 what Brinton, Johnson, Sir Thomas Watson, and other 
 early fathers have written upon the subject of dyspepsia. 
 With perfect accuracy of observation in many instances, 
 with supreme mastery of English in almost all, they tell the 
 story of many of the forms of dyspepsia. But none of 
 them realised, as we by degrees have come to learn, that 
 dyspepsia is so often a manifestation not of a nervous or 
 functional disorder, but of a real organic change. The 
 story of how this all came about may bear retelling. 
 
 In the early days of gastric surgery operations were 
 undertaken either for the relief of patients afflicted with 
 carcinoma, after the methods laid down by the great pio- 
 neer and master, Billroth; or for the treatment of cases 
 of pyloric obstruction by the operation of gastro-enteros- 
 tomy, suggested in a whisper by Billroth's assistant, Nico- 
 ladoni. Of cancer I have at this moment nothing to say. 
 In cases of pyloric obstruction the operation gave results 
 which were quite amazing in their character and rapidity. 
 12
 
 178 ESSAYS ON SURGICAL SUBJECTS 
 
 Patients, emaciated almost to the last degree, unable to 
 take more than the most meagre of meals, afflicted with 
 copious vomiting at intervals of only a few days, became in 
 two or three weeks happy mortals, with keen relish for 
 food, which gave no unease, and which was retained with- 
 out difficulty. Many patients underwent a veritable 
 resurrection; one of my patients weighed 51 Ibs. when 
 operated upon and a few years later weighed 131 Ibs., 
 and in several instances I have known the weight to be 
 doubled. 
 
 "GASTRIC ULCER" IN THE RIGHT ILIAC FOSSA 
 
 So marvellous were these results that the eager activity 
 of surgeons led them to employ the same method in other 
 cases of "gastric ulcer." Patients who for years had 
 suffered the misery or the martyrdom of indigestion 
 readily submitted to any operation offering a prospect 
 of relief. But it soon became apparent that the results 
 were not so brilliant in the later as in the earlier cases, 
 and the dreadful mistake was widely made of accepting 
 the diagnosis of "gastric ulcer" as positive in ah 1 patients 
 who presented the symptoms which the text-books of 
 medicine had told us were pathognomonic of the disease- 
 Patients who suffered from pain, vomiting, and haemat- 
 emesis were held to be the victims of "gastric ulcer," 
 and for gastric ulcer the approved surgical remedy was 
 gastro-enterostomy. Little by little the truth dawned 
 upon us that "gastric ulcer" was a perilous diagnosis to 
 make. For, with whatever confidence the existence of this 
 lesion was predicted, disappointment and dismay followed 
 fast upon the investigation of the parts. The stomach in 
 these cases often showed no trace of that hard white scar 
 which we knew must indicate the site of an ulcer of old
 
 THE GIFTS OF SURGERY TO MEDICINE 179 
 
 standing. For a long while we were at a loss to know what 
 the cause of the symptoms might be, when all the stomach 
 walls and the duodenum appeared healthy. The scope of 
 inquiry in such patients was therefore widened, and the 
 discovery made which excited the deepest disbelief in the 
 minds of many and which still meets with incredulity 
 the discovery that in the majority of cases which come to 
 an operation a "gastric ulcer" has its place in parts other 
 than the stomach. 
 
 There is now no longer any doubt in my own mind 
 that the commonest site of a "gastric ulcer" is in the right 
 iliac fossa. That is to say, that in the majority of cases in 
 which the most erudite teaching of the most astute Ger- 
 man physicians would justify or compel a diagnosis of 
 ulcer, the patient is suffering from a lesion elsewhere, and 
 more often than not from a lesion in the appendix. The 
 appendix may present a variety of conditions, but they are 
 all alike in one particular they are all obstructive in 
 character. Infection and obstruction together, or apart, 
 as Sir Bertrand Dawson has well said, make all the ills 
 from which a patient derives abdominal trouble. In the 
 appendix both may be at work at the same moment; in- 
 deed, one follows inevitably upon the other. In my ex- 
 perience there is no appendicitis without obstruction. In 
 these cases of mimicry of gastric ulcer is the stomach, 
 then, quite healthy? In my earlier and less complete 
 observations I often thought it was. Now I feel sure that 
 there is, I think I may say always, such a change in the 
 appearance of the organ as will enable the most absolute 
 prediction to be made that the appendix is diseased. 
 These changes are: a vivid injection, a deep congestion of 
 the pyloric portion of the stomach over a distance of two 
 or three inches at least; a great, irregular, eager activity of
 
 180 ESSAYS ON SURGICAL SUBJECTS 
 
 contraction, the muscles of the part appearing to writhe in 
 angry contortions; and thirdly, an enlargement of the sub- 
 pyloric group of glands. The explanation of these changes 
 is, I think, now clear; of their existence there is no longer 
 any doubt. The present position of our opinion is ac- 
 cordingly this, that in many of the cases of "gastric ulcer," 
 the symptoms of which are pain, flatulence, acidity, heart- 
 burn, vomiting, and haematemesis, the lesion primarily 
 responsible for such symptoms does not lie in the stomach. 
 The lesion is one in which infection and obstruction are in 
 league to do harm, and its most frequent location is in the 
 appendix. 
 
 The evidence seems to be increasing, and is, indeed, 
 already abundant, in favour of the view that these distant 
 infections, whether in the appendix or elsewhere, which 
 often produce the gross lesions just described in the 
 stomach, may be the precursors and the excitants of a 
 chronic ulcer of the stomach. The experimental work of 
 Turck, Bolton, and Wilkie has shown how liberation of 
 the gastric mucosa may be set up by infecting agents, 
 and may be perpetuated by the inability of the stomach 
 completely to empty itself in the normal time. To infec- 
 tion, stasis is added and often also an increased acidity, or 
 at least an acrimony of the gastric juice. Gastric ulcer, 
 then, would appear to be almost always a secondary dis- 
 order; the primary fault lies not in the stomach, but else- 
 where, its expression is manifest in the stomach because of 
 the particular series of incidents which occur therein. This 
 much is certain that when cases of gastric ulcer come to 
 the operation table the evidence of other and apparently 
 older lesions is rarely wanting.
 
 THE GIFTS OF SURGERY TO MEDICINE 181 
 
 CHRONIC ULCER AND CARCINOMA 
 
 Among the most notable of the gifts of surgery to 
 medicine is the proof that in a large proportion of cases 
 the onset of cancer of the stomach is not a new and un- 
 accountable thing, but is, on the contrary, a tardy devel- 
 opment upon an earlier condition which for years had 
 clamoured for recognition. It appears to me that the 
 work of the Mayo Clinic has offered irrefragable proof of 
 this assertion. 
 
 I am, of course, well aware that all cases of cancer 
 of the stomach, unhappily, do not come to the surgeon. 
 No one but the surgeon can do any good to patients so 
 afflicted. Yet there is a strange timidity of approach to 
 the surgeon which is unaccountable, and far too often the 
 favourable period in the history of a case is allowed to slip 
 away before any recognition of the real condition is at- 
 tempted. It is true, then, and must be admitted, that 
 when the surgeon speaks of the work which passes under 
 his hand he is not speaking of the whole. Nor is anyone 
 else. Neither the physician nor the post-mortem inves- 
 tigator knows the whole range of cases; indeed, each sees 
 far less nowadays than the surgeon. The view of the 
 latter, therefore, if not all-embracing, is doubtless wider 
 than that of anyone else. The experience of the surgeon 
 shows and here geographical considerations seem to 
 matter little that, roughly, two out of three of all pa- 
 tients who come for relief from a condition of carcinoma 
 of the stomach give a history of inveterate and recurring 
 dyspepsia over a stretch of many months or years. No 
 one knows so well as the surgeon, for he made and repeats 
 daily the discoveries, that such a history does not mean 
 that there is a chronic ulcer of the stomach, healing and
 
 182 ESSAYS ON SURGICAL SUBJECTS 
 
 breaking down afresh, during all that time. But though 
 we are grown chary of making a diagnosis of "gastric 
 ulcer" with that ease and certitude which formerly at- 
 tached to the physicians of all countries, we can and do 
 make an accurate diagnosis in a large proportion of the 
 cases, if only those patients are allowed to be suffering 
 from "gastric ulcer" who can hardly be supposed to be the 
 victims of any other organic lesion. The surgeon who 
 walks by sight and not by faith knows that a gastric ulcer 
 is a real thing, though so many imposters have claimed his 
 attention. In the majority of the cases of gastric car- 
 cinoma the history given of earlier attacks makes it almost 
 certain that these were due to a veritable ulcer of the 
 stomach. There may be, I fully admit, errors in this 
 estimate; but making all the allowances that our operative 
 experience warns us to be necessary, there can be, I think, 
 no doubt at all that a genuine chronic gastric ulcer has 
 been the cause of that dyspepsia of which recurring at- 
 tacks are noted. In one of these attacks, perhaps after 
 an interval of months or years of freedom, something dif- 
 ferent is noticed. The attack is heralded in the old way; 
 at first no difference between it and the others may be ob- 
 served. But by degrees it is realised that something 
 worse is occurring. The symptoms, which in earlier at- 
 tacks were so easily amenable to careful treatment, to rest, 
 to sparing diet, and so forth, have now become more severe 
 and incoercible. Relief does not come from the measures 
 which before have been so instantly successful. More- 
 over, weight is more rapidly lost, anaemia may develop, 
 and anorexia is most persistent and distressing. This is 
 the occasion, all other and more favourable occasions hav- 
 ing lapsed, when instant it can hardly be called preco- 
 cious surgical treatment should be urged. The patient
 
 THE GIFTS OF SURGERY TO MEDICINE 183 
 
 has now arrived at middle life, or has passed it, and the 
 diagnosis of cancer may tentatively be made and should 
 be acted upon with alacrity. Surgical intervention for 
 purposes of inquiry has hardly any mortality nowadays. 
 If a cancer be found and a resection of the stomach is 
 undertaken, the mortality will vary with the expertness 
 of the hands which practise it. But whatever that mor- 
 tality may be, it cannot attain the death-rate of inaction 
 and of "expectant" or medical treatment, which is ex- 
 actly 100 per cent. It was urged by Dr. W. L. Rodman 
 many years ago that resection of the pyloric end of the 
 stomach for the ulcers that singly or in clusters are found 
 there was the most prudent mode of treatment. In his 
 clinic at Rochester Dr. W. J. Mayo has for several years 
 resected the stomach not only for chronic ulcers in the 
 vicinity of the pylorus but also for those tumours which 
 might be due to ulcer or might be due to cancer, for de- 
 clared cancer and for those cancers which, though evi- 
 dently not curable because of the enlargement of distal, 
 secondary glands, or other visceral deposits, were yet re- 
 movable. In his so safe hands resection has hardly any 
 greater mortality than gastro-enterostomy. This pro- 
 cedure is questionless the ideal one. It has afforded, of 
 course, a unique series of specimens for investigation. 
 Dr. Wilson and Dr. MacCarty conclude from their ex- 
 amination of all the material so furnished that in 71 per 
 cent, of these cases of cancer of the stomach the malignant 
 process is engrafted upon a simple one, that cancer is 
 really due to a secondary change which starts in the edge 
 of an ulcer of long standing. My own material, far less 
 in quantity, bears out their contention. It has been 
 shown that in the base of these ulcers tending to cancer 
 the mucosa has gone, leaving only scar tissue ; in the over-
 
 i8U ESSAYS ON SURGICAL SUBJECTS 
 
 hanging border of the ulcers the mucosa is prolif crating, 
 and some epithelial cells, nipped off by scar tissue, are 
 showing all the stages of aberrant proliferation with in- 
 filtration of the surrounding tissues and metastases in the 
 lymphatic vessels of the stomach wall. The truth of these 
 observations is hardly yet admitted by those whose in- 
 quiry has been based only upon specimens found in the 
 post-mortem room or on the shelves of the museums 
 upon parts, that is, that have been long dead, and sub- 
 jected, no doubt, to the many changes which death and 
 swift decay bring in every cell. Upon the post-mortem 
 table only the final dilapidated ruin of the disease is seen; 
 in specimens removed during life the disease in its earlier 
 stages can be scrutinised. The material upon which the 
 pathologist has formerly worked has not been favourable 
 to the discovery of the truth ; the sources of eternal truth 
 were poisoned. 
 
 It would be hard to decide among so many strong com- 
 petitors as to the primacy of any piece of work given out 
 by the Mayo Clinic. It is, however, safe to say that the 
 real and permanent value of the contributions to this sub- 
 ject of cancer of the stomach, both from the technical and 
 the pathological sides, can hardly be overstated. 
 
 DUODENAL ULCER 
 
 The infection which has its origin in the appendix or 
 in the intestine wreaks other harm than that upon the 
 stomach wall. Of duodenal ulcer and of cholelithiasis we 
 have also learnt that they are usually secondary manifesta- 
 tions. Of duodenal ulcer I have so recently and so fully 
 written that it is not necessary here to do more than record 
 the fact that a full knowledge of its symptoms and course, 
 and the power, unrivalled in any other abdominal dis-
 
 THE GIFTS OF SURGERY TO MEDICINE 185 
 
 orders, of making an accurate diagnosis are not the least 
 important of the gifts of surgery to medicine. Of this 
 disease almost nothing was learnt after enquiry from the 
 dead alone, except of those late preventable disasters which 
 come from its unchecked course. In the early days of our 
 recognition of this condition we were assailed by a for- 
 midable array of post-mortem statistics which went to 
 show the rarity of the disorder, and the absence or the in- 
 constancy of any symptoms which could be attributed to it 
 during the life of the patient. We now know the great 
 frequency of the disease every month I operate upon 
 more cases than were formerly recognised in the post- 
 mortem room of the largest hospitals in ten years and the 
 claim may truthfully be made that of all abdominal dis- 
 eases none can be more certainly discovered by a scrutiny 
 of the anamnesis alone. 
 
 THE ETIOLOGY OF GALL-STONES 
 
 Another and equally important reversal of opinion has 
 occurred in connexion with cholelithiasis. It was for- 
 merly the accepted belief, and as fallacies die hard may still 
 be the view of some, that in a large percentage of cases 
 gall-stones were "innocent"; they declared their presence 
 by no apparent sign, and their existence threatened no 
 peril to the health or life of the patient. 
 
 The work of Lartigau upon the etiology of gall-stones is 
 of the first importance. He showed that active organ- 
 isms taken up by the portal stream from the intestine were 
 passed through the liver, which acted as a "destructor." 
 They emerged from it in the bile, lifeless. Some few, how- 
 ever, under special circumstances, made their escape, and 
 remained active in the bile which flowed to the intestine. 
 If the organisms which find their way into the gall-bladder
 
 186 ESSAYS ON SURGICAL SUBJECTS 
 
 are violent in their activities an acute inflammatory con- 
 dition, of a degree which varies with the intensity of the 
 infection, is caused. There may be any gradation from an 
 acute phlegmonous cholecystitis to a trivial and evanes- 
 cent catarrhal condition of the mucosa. If the germs be 
 in an attenuated condition the contractile power of the 
 gall-bladder is competent to expel them, and no harm re- 
 sults. So far as experiment serves to show, a stone can 
 only develop in the gall-bladder (and the gall-bladder is 
 the factory wherein all stones are made) if, with a miti- 
 gated culture of micro-organism, there is some retarda- 
 tion of the outflow of bile. Sepsis and stasis must go to- 
 gether. The gall-bladder then puts forth its own efforts 
 to protect itself, and secretes cholesterin, which being de- 
 posited upon the surface of the germs, clumped as they 
 probably are, safely immures them. A gall-stone, then, 
 consists of a deposit of cholesterin (alone, or with the addi- 
 tion of other salts) upon a nucleus of organisms which have 
 intruded into the gall-bladder. Every gall-stone, as I 
 have said before, is a tombstone erected to the evil memory 
 of the germs that lie dead within it. The frequency with 
 which gall-stones lie inert within the gall-bladder, causing 
 no harm and arousing no symptoms, is so very small as to 
 be quite negligible. It is certainly much less than 1 per 
 cent, in all those cases which come for surgical treatment, 
 and, though I admit that this estimate involves a possible 
 fallacy, yet the truth cannot be known of all the cases in 
 which gall-stones exist, for neither operative work, nor the 
 examinations of the dead, nor the records of the "spas," 
 reveal the whole matter.
 
 THE GIFTS OF SURGERY TO MEDICINE 187 
 
 THE INAUGURAL SYMPTOMS OF GALL-STONES 
 
 The error that has found a place in the minds of all 
 medical men, and has been faithfully carried down from 
 one generation of text-books to another that in the 
 majority of cases gall-stones cause no symptoms has 
 been forever dispelled by the work of the surgeon. In 
 operating upon cases of advanced cholelithiasis a history 
 of inveterate though perhaps trivial dyspepsia over a long 
 period can almost always be obtained. In operating upon 
 patients for the relief of other conditions myoma of the 
 uterus, ovarian or other pelvic conditions, appendicitis, or 
 ulcer in the stomach or duodenum a routine examination 
 of the gall-bladder and kidneys should be made. Every 
 now and again stones will be found in the gall-bladder, 
 and far more rarely in the kidneys. In the case of the 
 former a clear history of dyspeptic troubles can, in my 
 experience, invariably be obtained. It is true that these 
 symptoms are not those which are commonly recognised 
 as being due to a gall-bladder condition, but the gift of 
 surgery to medicine consists here in the true portrayal 
 of those clinical manifestations which only an examina- 
 tion of the living could disclose. We now know that the 
 earliest symptoms, the "inaugural symptoms," of chole- 
 lithiasis are just as characteristic, just as certainly to be 
 recognised, as those of the later sequels and avoidable 
 complications. And more than this: the very little that 
 was known of cholelithiasis in its clinical aspects has un- 
 dergone a complete revision, with the result that we are 
 often able to declare not only the presence of stones, but 
 often the position of that which is causing the most serious 
 trouble. The only circumstances under which symptoms 
 are not at the moment aroused by stones which lie within
 
 188 ESSAYS ON SURGICAL SUBJECTS 
 
 the gall-bladder exist when the cystic duct has become 
 permanently closed and the walls of the gall-bladder, 
 thick, and white, and hard, embrace firmly the stones that 
 lie harmless within it. This is the "natural cure" of 
 Rutherford Morison, a condition which develops only after 
 months or years of symptoms, often of great severity. It 
 is Nature's cholecystectomy, and though Nature may be 
 an admirable physician, her skill as a surgeon is of the 
 lowest order, and her work cumbersome, clumsy, and 
 dangerous. 
 
 LESIONS OF THE PANCREAS 
 
 It is as an outcrop of the work of the surgeon on gall- 
 stones that all our modern knowledge of the clinical aspects 
 of chronic pancreatitis has sprung. The acute form of 
 pancreatitis was first recognised and, with something 
 nearly approaching to finality, described by one of the 
 greatest of physicians Dr. Fitz of Boston. But of 
 chronic inflammation, of stone, of cysts, and of the mim- 
 icries of cysts nothing was heard or known till the sur- 
 geon came bearing these gifts in his hands. 
 
 We know well the great change that comes over all 
 parts of the body after death; the face changes, wrinkles 
 are smoothed away, the cheeks sink in, the eyes are lustre- 
 less, the orbits hollow. Other parts change equally, and 
 among them the pancreas, perhaps, most of all. In a 
 case of acute pancreatitis the gland, at the moment of 
 operation, seems one massive phlegmon tumid, doughy, 
 and with no abrupt margin. After death it appears to 
 be merely a bruised and blood-stained organ. So with the 
 gland in a state of chronic inflammation. To the hand of 
 the operator it may feel large and densely hard, and it may 
 be responsible for the obstruction and a considerable dila- 
 tation of the common bile-duct. After death it seems
 
 THE GIFTS OF SURGERY TO MEDICINE 189 
 
 hardly altered from the normal, and certainly in earlier, 
 less exact days would not have attracted close attention. 
 The evidence of the operator and the pathologist was then 
 incompatible, because neither seemed to recognise that 
 their approach to the problem was from different points 
 of view. 
 
 The question of chronic pancreatitis was first brought 
 before the minds of surgeons by Riedel, who noticed that 
 in many operations upon the biliary passages the pancreas 
 was large, hard, and unduly firm. In three recorded cases 
 he believed the patient to be suffering from carcinoma of 
 the head of the gland, and he gave, accordingly, a hopeless 
 prognosis. Two patients recovered, and remained per- 
 fectly well; the third patient died, and the examination of 
 the pancreas showed no trace of malignancy, but the plain 
 evidences of a chronic interstitial inflammation. Little 
 knowledge, however, sprang from this observation, until 
 Mayo Robson, with his then unrivalled experience of chole- 
 lithiasis, showed the frequency and the clinical importance 
 of pancreatitis, and convinced us all of its powers of 
 mimicry both of carcinoma and of the calculous form of 
 common duct obstruction. 
 
 Its mimicry of carcinoma may be complete. Pain- 
 lessly and progressively the patient may develop jaundice, 
 which continues to deepen until the "black jaundice" of 
 the older writers can be recognised. There is great loss 
 of weight and prostration, hebetude and misery, though 
 often the appetite is unimpaired. The liver enlarges and 
 the gall-bladder distends to a degree which allows it to be 
 easily seen and felt protruding below the rib margin. In 
 accordance with the law of Courvoisier we assume that 
 such a dilatation of the gall-bladder is due to causes other 
 than stone. An examination of the stools might show a
 
 190 ESSAYS ON SURGICAL SUBJECTS 
 
 complete absence of bile pigment, and this may seem the 
 most conclusive evidence of carcinoma, for a chronic in- 
 flammation, however inveterate, rarely causes an abso- 
 lutely impermeable block to the passage of bile. 
 
 CHOLECYSTENTEROSTOMY 
 
 With the history of a condition such as this, one could 
 hardly fail to make a diagnosis of growth and predict a 
 speedy ending to the case. But no one living is infallible 
 in the differential diagnosis of obstructive jaundice. The 
 diagnosis is always so difficult, and the chance of a life 
 saved so important, that, however positive the evidence of 
 malignancy may be, I advise operation in all cases. So far 
 as immediate amendment is concerned, there is little to 
 choose between the malignant and the benign cases. In 
 both the patient begins to improve, the jaundice falls 
 away slowly, sometimes very slowly, and weight is soon 
 gained. The operation performed consists in joining the 
 gall-bladder to the intestine, to the duodenum if easily 
 available (it may be quite inaccessible, lying high and 
 remote, when the liver is enlarged and the gall-bladder 
 over-full), or to the stomach. It may be feared that when 
 all the bile passes directly into the stomach, nausea, vomit- 
 ing of bile, or loss of appetite results. Such fears are 
 groundless. I have joined the gall-bladder to the stomach 
 in more than 20 patients who have survived a year or more, 
 and there is no suspicion of any special discomfort attach- 
 ing to the operation. I have patients living still upon 
 whom I operated four, six, and seven years ago in the 
 confident belief that they suffered from carcinoma and 
 would shortly be dead. It is impossible for the most 
 astute clinician or the most subtle pathologist to discover 
 by physical signs, from the anamnesis or from the chem-
 
 THE GIFTS OF SURGERY TO MEDICINE 191 
 
 ical examination of urine and faces, whether a simple or 
 cancerous disease is present. He may shrewdly guess, 
 but a guess is a poor peg on which to hang a man's life. 
 All cases of obstructive jaundice should be operated upon; 
 the mortality of cholecystenterostomy now is trifling if we 
 take into account the severity of the disease and the out- 
 look. Apart altogether from the prolongation or saving 
 of life, almost every patient will declare that the relief 
 from the maddening torture of itching is worth every sac- 
 rifice. 
 
 Acute pancreatitis, so accurately described by Fitz, 
 remained for long a desperate and often lethal disorder. 
 The onset of the symptoms was so abrupt, their course so 
 rapid, and the fatal event so precipitate that for many 
 years surgeons were quite unable to realise the moment 
 for swift intervention. When operation was undertaken 
 it was generally upon the mistaken diagnosis of perforating 
 ulcer of the stomach or duodenum. And it was not until 
 Ramsey, in 1902, showed that the chief surgical indication 
 here, as in the case of a phlegmon in the extremities, 
 consisted in the relief of tension that success began to 
 attend the surgeon's efforts. Now it is a matter of very 
 little difficulty to make an accurate and timely diagnosis 
 of acute pancreatitis, and the recovery of the patient can 
 generally be assured. A tribute here may fittingly be paid 
 to the work of Simon Flexner and Opie, who showed how 
 apt an intense inflammation of the gland is to follow upon 
 the infection of its duct by bile, by chemical irritants, or 
 by infective agents. Acute pancreatitis is not seldom 
 associated with cholelithiasis, bile which is obnoxious to 
 the gland passing from the common duct to the canal of 
 Wirsung when the orifice of the ampulla is blocked by a 
 tiny stone.
 
 192 ESSAYS ON SURGICAL SUBJECTS 
 
 Other diseases of the pancreas, cysts and calculi, have 
 lent themselves also to accurate diagnosis and successful 
 treatment by the surgeon. One of the very ablest and 
 most original papers contributed to the literature of sur- 
 gery in my time appeared in the British Medical Journal 
 in 1892 (vol. ii, p. 1051). It was written by the great 
 surgeon and my very good friend, who preceded me in the 
 delivery of this annual address, the late Jordan Lloyd. 
 He pointed out that, contrary to the generally received 
 opinion, the fluid tumours appearing in the epigastrium 
 after the receipt of an injury were not veritable cysts of the 
 pancreas, but accumulations of fluid in the lesser sac of the 
 peritoneum which had closed at the foramen of Winslow. 
 Calculi are rarely found in the pancreatic ducts. Their 
 presence has been recognised, and in a few cases the stones 
 have been successfully removed, since the inauguration of 
 surgical treatment by Pearce Gould in 1896. 
 
 THE SOURCE OF INFECTION IN THE ABDOMEN 
 
 Among the most interesting and possibly one of the 
 rich gifts of surgery to medicine is the hypothesis that 
 intestinal stasis, with the associated condition of absorp- 
 tion of toxins, is responsible for many of the diseases which 
 attack not only the abdominal viscera, but even also parts 
 remote therefrom. Perhaps no subject in medicine to-day 
 has received more discussion, has been more bitterly 
 assailed, more often attacked by derision rather than by 
 argument, and more cheerfully supported than this. Its 
 author, Arbuthnot Lane, is a man whose mind moves 
 easily along new paths. Such a pioneer has often reached 
 his destiny before other tardy travellers have set out upon 
 the way. The pioneer in all branches of knowledge rarely 
 himself reaches the truth he is more apt to overreach, or
 
 THE GIFTS OF SURGERY TO MEDICINE 193 
 
 to be content to guess the road that lies ahead without 
 beating it down with his own foot tread. 
 
 In contemporary surgical history many observers, as I 
 have pointed out, have had their minds attracted to a firm 
 belief in one thing namely, that many of the diseases for 
 which surgery is called upon to deal are not primary dis- 
 orders, but are secondary; that they depend for their exist- 
 ence and extended development upon some common cause ; 
 and that this common excitant is an infection which ex- 
 presses itself now in one way, now in another. The con- 
 ditions I have already mentioned ulcer of the stomach or 
 duodenum and cholelithiasis are, in the belief of all of us 
 who do much work for their relief, really dependent upon 
 an infection. For my own part I look upon the appendix 
 as the most potent and the most frequent cause of offence. 
 Arbuthnot Lane takes a wider view. He believes that 
 the intestine itself is the factory in which the poisons are 
 produced, w T hich cause, or make more easily possible, not 
 only the various conditions I have named, but also such 
 diverse and distant conditions as "rheumatoid arthritis," 
 tuberculous disease of bones and joints, diseases of the 
 breast, cystic and malignant, of the thyroid gland, and 
 many other conditions. At first it was supposed that 
 the large intestine was the malefactor, and some slender 
 support was possibly derived for the hypothesis from the 
 work of Metchnikoff and others. More recently the de- 
 layed drainage of the small intestine has been held more 
 blameworthy. Various bands and kinks have been de- 
 scribed in different parts of the alimentary canal, and 
 these have been held responsible for the obstruction, 
 behind which dilatation and stagnation occur. Con- 
 troversy has raged around the question as to whether 
 these veils and kinks were developmental in'origin, inflam- 
 
 13
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 matory, or evolutionary; and very often the opinions of a 
 writer are formed exclusively upon, or prejudiced by, the 
 one out of many possible methods of examination to which 
 he has devoted exclusive attention. The terminal ileal 
 adhesion, for example, which is held by many to be the 
 most powerful of all for evil, clearly owns at least two en- 
 tirely different origins. The most common form of it, in 
 my view, is that which depends upon inflammation of the 
 appendix. But it is interesting to recall that in my book 
 on "Retroperitoneal Hernia," published 14 years ago, I 
 point out that the "physiological fusion" of Toldt occurs 
 to excess in two parts of the small intestine, with the result 
 that there occurs "an adhesion of the upper few inches of 
 the jejunum, or the lower few inches of the ileum to the 
 posterior abdominal wall." I point out there, moreover, 
 a possibility which is constantly overlooked, that this 
 physiological agglutination is not a process which ends 
 abruptly at birth, but that it continues afterwards; it is 
 possible, indeed probable, that it gradually advances dur- 
 ing adult life. So far as the large intestine is concerned, 
 my own experience points to the splenic flexure as the 
 part where an arrest in the flow of contents is most prone 
 to occur. Whether this is due to an exaggeration of the 
 normal ligamentous attachments of the flexure, to its ex- 
 treme fixity, or to the dragging effects of an overweighted 
 and powerless transverse colon I cannot say. But there 
 can be no doubt that obstruction of the most acute, as of 
 the most chronic, kind may be solely dependent upon 
 "kinking" of the large bowel at its splenic flexure, sur- 
 rounded and held firm by membranous adhesions. 
 
 But these points, after all, are only incidental. The 
 main question is concerned not with the exact means by 
 which effects are produced, but rather with the existence
 
 THE GIFTS OF SURGERY TO MEDICINE 195 
 
 of the alleged effects. The fervid apostles of the new creed 
 are a little prone to bewilder us with reasons for their im- 
 mature observations. This is only to darken knowledge 
 and to encumber their religion with dogma. We need 
 not yet be greatly exercised over the terms of an explana- 
 tion of how these effects come about, for in medicine ex- 
 planation often lags far behind experience. The most ex- 
 emplary instance of the effects of alimentary toxaemia oc- 
 curs, perhaps, in the condition which may best be de- 
 scribed as Lane's disease. The miserable chronic dys- 
 peptic with sallow skin, dirty tongue, flaccid belly, offen- 
 sive breath, dusky lips and nails, cold extremities, and 
 constipation that is with some difficulty overcome, is 
 restored to health with incredible rapidity when a short 
 circuit is made between the ileum and the pelvic colon. 
 The claims that Lane makes in respect of such patients 
 must indubitably be admitted. I have never in these 
 cases, nor, indeed, in any of "alimentary toxaemia," found 
 it necessary to consider the question of a removal of the 
 entire colon. As to the further claims which are made, I 
 have not yet arrived at the point where I can admit 
 them, but the hypothesis charms by its simplicity, and 
 attracts by its magnitude, and I am travelling hopefully. 
 
 THE SUCCOUR OF THE INDIVIDUAL AND THE SERVICE OF 
 
 THE CAUSE 
 
 Medicine in its quest of knowledge may rightly levy a 
 tribute from every other science with which it comes into 
 contact. Its doctrines and its practise are tested, may 
 receive support, or be refuted, by work accomplished in 
 other fields. Surgery in recent years has proved a 
 powerful helpmeet not only in the elucidation of those 
 problems of internal medicine to which I have briefly
 
 196 ESSAYS ON SURGICAL SUBJECTS 
 
 referred, but also by reason of the light it has brought to 
 bear upon the functions of many of the organs in the 
 body. The experimental method, as a mode of enquiry, is 
 not excelled in value by any other, and no experiments, 
 I hold, can claim an equal rank with those which are a 
 part of almost all surgical procedures. The chief glory of 
 the surgeon comes from the dedication of his powers to 
 the service of an individual; but there is a cause also to 
 be served. In every operation something may be learnt, 
 not only of those disorders which call urgently for relief, 
 but of other associated, or it may be separate, conditions 
 which chance at the same moment to be present. The 
 researches so carried out upon a human patient are per- 
 formed with a sterner sense of responsibility and with a 
 graver ritual, and are impressed by more relevant influ- 
 ences than attach to any other form of enquiry. Their 
 results are accordingly of far higher value. Clinical re- 
 search, when sedulously conducted and illuminated by the 
 disclosures made upon the operation table, affords the 
 most accurate of all methods of investigation into the dis- 
 eases by which man is attacked. The succour of an indi- 
 vidual should mean also the taking of a step forward in 
 the solution or the better understanding of the manifold 
 and perplexing problems of disease.
 
 THE SURGERY OF THE CHEST IN RELATION 
 TO RETAINED PROJECTILES 1 
 
 WHAT is the fate of patients who have received wounds 
 of the chest, and who harbour a projectile within the 
 thoracic cavity? There are doubtless many hundreds, it 
 has even been asserted that there are thousands, of men 
 now in England in whose lungs a projectile is retained. 
 At the present time the evidence as to the discomforts or 
 dangers to which they are prone is conflicting. It is con- 
 flicting because it is incomplete. On the one hand we 
 hear that some few men, the bearers of a foreign body that 
 is lodged in the lung or in the mediastinum, suffer very 
 little; are almost forgetful of the fact that they have been 
 wounded; and continue their civil work, sometimes per- 
 haps very arduous, without suffering any disability which 
 might lessen their value in the labour market. On the 
 other hand we find that pensioners come, in small numbers 
 it is true, to the civil hospitals, making complaints of the 
 distress they experience, and asking for the removal of the 
 projectile which they believe to be the cause of their suf- 
 fering. In these latter cases it is neither the physical 
 properties of the retained projectile nor the presence of 
 infection around it which are alone to blame. For, of all 
 the forms of projectile, a shrapnell ball or a rifle bullet 
 might be supposed to be the least harmful. Their sur- 
 faces are smooth, and except at the point of a rifle bullet 
 no injury is likely to be cause'd by the chafing of the pro- 
 jectile against the tissues on movement. Yet patients 
 with these forms of foreign body seem to complain as much 
 as do those in whose chests a sharp, jagged piece of metal 
 
 1 Reprinted from The British Journal of Surgery, Vol. VII, No. 28, 1920. 
 
 197
 
 198 ESSAYS ON SURGICAL SUBJECTS 
 
 is lodged. Nor is the degree of infection alone responsible, 
 as is seen from the record of a case where a sterile rifle 
 bullet was found embedded in lung tissue. Except for the 
 greater likelihood of post-operative troubles, such as sup- 
 puration of the wound, or empyema, there does not appear 
 to be any conspicuous clinical distinction to be made be- 
 tween those cases in which the foreign bodies are infected 
 and those in which the projectile is sterile. And it is in- 
 teresting to note that, although the lung is admittedly as 
 capable of defending itself against microbic attack as any 
 part of the body, an active infection may be found upon a 
 projectile removed after three years' lodgement in the 
 parenchyma. 
 
 Nor does the position of the foreign body in the lung 
 afford any constant clue as to the cause of the symptoms 
 of which complaint is made. It is true that if the foreign 
 body lies in, or in contact with, the heart, the anxiety of 
 the patient as to his future is increased. But whether a 
 missile is lodged in one part of the lung or another does not 
 seem to be of importance, so far as the existence or the 
 severity of the chief symptoms is concerned. 
 
 The frequency, therefore, with which symptoms are 
 present in the case of those harbouring projectiles in the 
 chest is uncertain. So far as an enquiry is concerned which 
 cannot pretend to statistical accuracy, it appears to be 
 certain that the great majority of men make some com- 
 plaint of subjective phenomena. So long ago as 1916, 
 Denechau, in an enquiry into the condition of fifty patients 
 whose wounds dated back many months, elicited a history 
 in every case of subjective disorders. In the tunes of 
 active warfare we were all naturally and properly suspi- 
 cious of purely subjective complaints. Scepticism and 
 incredulity were our defence against the blandishments
 
 THE SURGERY OF THE CHEST 199 
 
 and the special pleading of many an "old soldier." But 
 the similarity of the symptoms in a long series of cases, 
 where collusion is impossible, makes it unlikely that ma- 
 lingering alone is responsible. Exaggeration there may be, 
 but similarity or identity of invention in many patients, 
 at long intervals of time, and widely separated geographic- 
 ally, is unlikely. And it was not long, in my experience, 
 before patients who had been discharged from the army 
 returned to hospital still complaining of their symptoms, 
 and were willing, even eager, to submit to operation for 
 their relief. So that if we discount fully the element of 
 exaggeration, we are still confronted by a considerable 
 body of evidence which goes to show that a projectile re- 
 tained in the chest is a source of discomfort, variable in 
 intensity, duration, and frequency, and of serious anxiety. 
 In my early experience I refrained from operating upon 
 many patients, partly from ignorance of several matters 
 concerned with intrathoracic surgery, and partly in the 
 hope that delay in operating would allow of the firm en- 
 capsulation of the projectile, and the gradual recovery of 
 the lung to a normal condition, or to a condition so nearly 
 approaching the normal as to encourage the patient to re- 
 turn happily to full work. My advice to patients not to 
 submit to operation was not always well received; and 
 often I was urged to consider the removal of the projectile, 
 as the patient was prepared to take the risk, though I had 
 spoken of it in terms which now I realize were unduly 
 grave. 
 
 In endeavouring to decide upon the principles which 
 should govern us in the advice we give as to the removal 
 of projectiles from the chest, we have to consider, on the 
 one hand, the pathological conditions caused by the en- 
 trance of the projectile, the severity of the symptoms
 
 200 ESSAYS ON SURGICAL SUBJECTS 
 
 aroused, and the prospects of increasing or diminishing 
 discomfort, disability, or danger from the continued lodge- 
 ment of the foreign body or from the changes aroused at 
 its rude entrance; and, on the other hand, the severity of 
 the operation necessary for the removal of the missile, the 
 mortality, the post-operative discomforts, and the results 
 as expressed in the altered conditions in the chest, and in 
 the consecutive changes in those symptoms for which the 
 patient first sought relief. 
 
 Among the projectiles found in the chest cavity, frag- 
 ments of shell are the commonest. They are usually of 
 small size, rarely more than an inch in length; they have 
 rough and pitted surfaces, jagged edges, and sharp points. 
 In a small proportion of cases fragments of clothing are 
 carried in with the metal, and are found lying with it in the 
 chest. In most instances there is only one piece of metal. 
 Machine-gun or rifle bullets are found, and shrapnel balls. 
 On one occasion in a series of cases a shrapnel ball was 
 loose in the pleural cavity, in which it could be seen to roll 
 about freely. It is very rare to find a large piece of metal 
 in the chest; the probability is that all patients into whose 
 chests such a foreign body penetrates, die as the early re- 
 sult of their injury. 
 
 I propose to consider the subject in the following order: 
 
 A. Pathological changes caused by projectiles within 
 
 the chest. 
 
 B. Symptoms to which they give rise. 
 
 C. Operations for the removal of projectiles. General 
 
 principles. Indications for operation. Opera- 
 tions: (1) Method of Petit de la Villeon; (2) 
 Marion's method; (3) Duval's method; (4) 
 Operations upon the root of the lung; (5) Op- 
 erations upon the mediastinum.
 
 THE SURGERY OF THE CHEST 201 
 
 D. After-history, and results of operations. 
 
 E. List of cases treated by operation. 
 
 A. PATHOLOGICAL CHANGES CAUSED BY PROJECTILES 
 WITHIN THE CHEST 
 
 1. Wound of Entry. As a rule, the wound made by the 
 projectile on entering the chest has healed. In the major- 
 ity of the cases I have seen, the wound is in the chest wall 
 (it may be in the neck or in the abdomen), sometimes on 
 the side where the projectile has lodged, sometimes on the 
 other side, a portion of the opposite pleural cavity and the 
 mediastinum having been traversed before the missile 
 comes to rest. It is very remarkable to find that the medi- 
 astinum with all its contents may be pierced by a bullet 
 or a fragment of shell, and yet the parts apparently suffer 
 not the slightest injury. The supple and elastic vessels 
 seem to yield place to the swiftly-moving metal ; they cer- 
 tainly escape damage in a manner that sometimes appears 
 incredible. In a few instances the bullet has passed 
 through the arm into the chest; and in one case of mine 
 some fragments of the humerus had been carried into the 
 lung. The rib at the point of entry may be fractured, 
 and minute fragments and splinters of the bone be swept 
 inwards to the pleural cavity and the lung; a similar lesion 
 may occur in the scapula or the sternum. It is the rule to 
 find only one wound of entry, but, as in other parts of the 
 body, the superficial lesions may be multiple, many frag- 
 ments of splintered metal entering the chest wall, one or 
 more of them passing through the parietes to lodge in the 
 lung tissue. 
 
 The same conditions in respect of the missiles and their 
 effects upon the soft parts are found in the chest as in the 
 tissues of the limbs. The damage inflicted depends upon
 
 202 ESSAYS ON SURGICAL SUBJECTS 
 
 the size and shape of the projectile, its physical properties 
 in respect of roughness and sharp edges, and its velocity. 
 A rifle bullet discharged at a distance of 1500 yards, when 
 its flight has become steady, may pass through the chest, 
 cleaving its way, and leave behind very little evidence of 
 trauma. A small fragment of coarse metal of ugly shape 
 and lower velocity may bruise and tear and crush any- 
 thing that lies in its path. 
 
 Wounds of the chest are often found in association 
 with wounds elsewhere: in the abdomen, extremities, or 
 head. Not only is the immediate problem of appropriate 
 treatment affected thereby, but also the duration of con- 
 valescence and the quality of the ultimate recovery. 
 
 2. The Path of the Projectile. So far as the soft parts 
 are concerned, the lesions at once produced, and the con- 
 ditions remaining after healing, are, as I have said, not 
 different from those seen elsewhere. In the lung itself 
 the course taken by a piece of metal can often be felt as a 
 thick cord or strand when the lung is grasped in the hand. 
 It is interesting that, in most instances, the foreign body is 
 found near the surface of the lung; rarely in the middle of 
 a lobe. It would seem that the central lung tissue itself 
 offers very little resistance to the passage of a fragment of 
 metal, which is brought to rest by the increased resistance 
 it meets at the surface of a lobe. The projectile itself may 
 be found at the very surface of the lung, embedded in ad- 
 hesions of great thickness and density. In some instances 
 it is not easy to say whether it has lain actually within the 
 substance of the lung, or in masses of lymph deposited on 
 the visceral pleura. 
 
 Two or three times, in separating the lung from the 
 chest wall as gently as possible, I have felt the foreign 
 body drop into my hand. The surface of the lung, when
 
 THE SURGERY OF THE CHEST 203 
 
 examined, merely showed a shallow pit with a rough and 
 shaggy wall. In other instances the metal is frankly in 
 the lung tissue, which has to be incised in order to release 
 the foreign body. The lung may then show signs of 
 "hepatization," being thick, hard, and red. Or in rare 
 instances the metal may be surrounded by a very thick 
 yellow fibrous capsule, within which are the remains of a 
 small collection of dried pus. 
 
 In one case of mine the tissue cut through resembled 
 exactly the structure and consistence of a calcareous mes- 
 enteric gland, and for a moment I was inclined to think 
 that the condition with which I was dealing was tubercu- 
 lous. But as I cut deeper into the dense tissues I felt the 
 metal against the knife, and a small fragment of shell-cas- 
 ing was released. Complete encapsulation of any foreign 
 body is extremely rare. It is not often that a piece of 
 clothing is found with the metal; when so found it is dark, 
 deeply blood-stained, often offensive, and always infected. 
 In two cases bronchiectasis was present, caused, no doubt, 
 by the pressure of a fragment of metal of rather large size 
 upon a large bronchus. In both cases expectoration be- 
 fore operation was profuse, and sometimes foetid; in both 
 there was local collapse of the lung, and in both the con- 
 dition was seen on x-ray examination. 
 
 3. Condition of the Pleural Surfaces. This varies with- 
 in very wide limits. I have often been struck by the ap- 
 parent discrepancy between the pathological conditions 
 discovered in the chest at the time of operation, and the 
 evidence of such conditions afforded by the ordinary 
 methods of clinical examination. It is evident that per- 
 cussion and auscultation, even by the most expert phys- 
 ician, reveal only the coarser defects, and do not always dis- 
 cover even them. What appear to the surgeon to be gross
 
 204 ESSAYS ON SURGICAL SUBJECTS 
 
 changes may be quite unrecognizable on clinical investi- 
 gation. 
 
 Adhesions of the two pleural surfaces are almost always 
 present. They may be of the slightest and flimsiest text- 
 ure, breaking down at the gentlest touch, and scattered 
 thinly over a limited area. They may be of considerable 
 density, and restricted to the line of flight of the foreign 
 body. A thick anchorage of adhesions is then found, and 
 the rest of the pleura may have few adhesions or none. In 
 other instances the two pleural surfaces may have become 
 so intimately adherent that it is possible to separate them 
 only by the exercise of the greatest force short of rough- 
 ness. Indeed, in some few instances I have been quite 
 powerless to separate adhesions, and have had to divide 
 them with knife and scissors; even then their severance has 
 been most difficult. In some instances the lymph poured 
 out has become organized into the densest and heaviest 
 felt-like material, which I have been able to dissect away 
 in large sheets, and to keep as a specimen. Where ad- 
 hesions are so very massive, they may isolate a small or 
 large collection of fluid, old blood-clots, desiccated pus, or 
 serum. Dense adhesions may be limited, only lying in 
 the path of the projectile, as I have just stated ; or they may 
 cover the whole of one lobe, the other lobe or lobes being 
 free; or virtually the whole of the pleural surfaces may be 
 involved. The lobes of the lung may adhere to each other. 
 The lung may adhere along the inner side to the medias- 
 tinum or to the pericardium. On the left side, especially, 
 it may be difficult to say whether a foreign body which 
 moves with the heart is in the edge of the lung, or on, or in, 
 the pericardium ; for the parts adhere strongly and are not 
 anatomically distinguishable one from another; a mass of 
 fibrous tissue binds them all together. In several in-
 
 THE SURGERY OF THE CHEST 205 
 
 stances I have found very strong adhesions of the lung to 
 the diaphragm, and the costodiaphragmatic angle has been 
 filled with the organized remains of old blood-clot or of a 
 pleural effusion. The immobility of the corresponding 
 hah of the diaphragm, as seen by x-ray examination, is 
 easily understood in such cases. 
 
 4. Infectivity of Projectiles. It was not always 
 thought proper to examine the projectile bacteriologically; 
 this was done only in those cases where the metal was 
 lifted directly out of its bed with sterile forceps, and held 
 while a smear was taken from it. In all, eighteen projec- 
 tiles were examined. In eleven there was infection by 
 Staphylococcus aureus, streptococci, pneumococci, or coli- 
 form bacilli. In seven the foreign body was sterile. 
 
 B. SYMPTOMS PRESENT IN CASES WHERE A FOREIGN 
 BODY is RETAINED IN THE CHEST 
 
 1. Pain. This is present in the affected side of the 
 chest. It is very variously described as "soreness," 
 "pricking," "stabbing," "burning." It is fairly constant, 
 but is increased when any exertion, work or play, is under- 
 taken. More than one patient has told me that he felt 
 then as though the side of the chest were being "held in a 
 clutch," and that the pain was insupportable and brought 
 with it a sense of acute anxiety and distress. The amount 
 or the quality of the pain suffered does not often appear to 
 have borne any very close relationship to the size of the 
 projectile, to the extent or position of the wound or wounds 
 of entry or exit, to the presence of operation wounds (in- 
 dicating that an effort has been made to deal with the pro- 
 jectile, or with the injured lung), to a former empyema, to 
 the restrictions in the movement of the diaphragm as dis- 
 covered by x-ray, or to the observed physical signs. It is
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 certain that the pain is no worse in those cases where very 
 extensive and extremely dense adhesions are present. In 
 several of my cases the pleural cavity was quite obliter- 
 ated, and the cohesion of the pleural surfaces was with 
 the utmost difficulty undone. Yet patients so afflicted 
 made no unusual complaint of pain. 
 
 Grey Turner has observed that pain and tenderness are 
 especially noticeable in cases where a localized area of ad- 
 hesions is found in the track of the missile where, that is 
 to say, a part only of the lung is firmly anchored to the 
 pleura, the rest being free to move. A general diffuse ad- 
 hesion, he says, between the pleural surfaces is not at- 
 tended with pain, and, indeed, may be a means of prevent- 
 ing it. These observations agree with my own. 
 
 In my earlier cases I was a little at a loss to account for 
 the pain of which so grievous complaints were sometimes 
 made, and I was almost persuaded that the knowledge of 
 the patient that a projectile was retained in the lung, to- 
 gether with a possible reluctance to be considered fit for 
 duty in the line, might be held largely responsible for the 
 manifold complaints. But this view was soon found to be 
 untenable when pensioners, who were no longer faced with 
 the possibilities of further service, who indeed had some- 
 thing to lose by being laid aside from work more remuner- 
 ative than ever before, came to the hospital seeking relief. 
 In them there was no need to estimate and to discount the 
 coefficient of exaggeration. 
 
 By degrees it became certain that pain in all such cases 
 was a real thing. In a large number of patients who have 
 missiles retained anywhere in the chest there is a consider- 
 able degree of apprehension as to their future, a far greater 
 degree, in my experience, than is found in men who have 
 pieces of metal lodged elsewhere. I know no reason for
 
 THE SURGERY OF THE CHEST 207 
 
 this, but the fact is beyond doubt. In the years 1915 and 
 1916 I saw seven patients who did not appear to me to be 
 suffering sufficiently to make it worth their while to sub- 
 mit to operation; all were dissatisfied with my advice to 
 have nothing done, and most of them came back finally 
 for operation. 
 
 2. Dyspnoea. This varies greatly in different cases. 
 It may be felt only on severe or protracted exertion ; it may 
 be slight even then. Or it may be an almost constant 
 symptom, present when the patient is in repose, greatly 
 augmented when he walks hurriedly, and especially on 
 going upstairs or on climbing a hill with an eager pedes- 
 trian. There are times when pain and dyspnoea together 
 produce a crisis of exhaustion, and the patient almost col- 
 lapses in an agony of distress. I have twice seen patients 
 in this condition when walking near the hospital. The 
 dyspnoea on repose and the effort dyspnoea, in all proba- 
 bility, are both due to embarrassment of the lung crippled 
 by adhesions, or to the massive remnants of an old haemo- 
 thorax, or to the shrinkage of the side of the chest and the 
 mediastinal displacement and collapse of the lung which 
 follow an empyema. There is not always a correspond- 
 ence between the degree of distress and the amount of 
 physical incapacity or deformity of the chest. 
 
 3. Cough. This symptom is frequent as a rule, indeed, 
 in some degree constant; though there are intervals in 
 which it may be in abeyance, especially if the patient is 
 kept in bed, or is bedridden by another lesion. Its pres- 
 ence is due not so much to the metal in the chest, as to 
 such associated conditions as sinuses leading down to the 
 pleural cavity or into the lung; to infection around the 
 foreign body, causing local hepatization of the lung, or 
 abscess; or to bronchiectasis or emphysema.
 
 208 ESSAYS ON SURGICAL SUBJECTS 
 
 When an external sinus leads into the lung, its tempo- 
 rary closure may coincide with a period in which a teasing 
 cough is accompanied by the copious expectoration of pus. 
 
 In a few cases haemoptysis occurs. It is not often 
 severe, but may be repeated on several occasions. It ap- 
 pears especially apt to follow on severe exertion. The 
 first case in which I saw it occurred in a man wounded in 
 September, 1914; a large fragment of shell-casing was re- 
 tained in the lower lobe of the right lung. The wound 
 healed, and in April, 1915, he was returned as fit for duty. 
 He was given bayonet practice, and a sharp haemorrhage 
 occurred at once; a like experience followed on two occa- 
 sions within a few days, and he then consulted the regi- 
 mental medical officer. 
 
 I have seen three cases in which pain, dyspnoea, cough, 
 purulent expectoration, and haemoptysis have been present 
 and have led to a diagnosis of pulmonary tuberculosis. 
 Similar cases are recorded by Delmas and Fiolla. In one 
 of my cases an x-ray diagnosis of a piece of metal retained 
 in the lung was made, and an operation performed. No 
 foreign body was found. The patient was subsequently 
 stated to be suffering from phthisis. 
 
 The expectoration is sometimes abundant, frothy, 
 purulent, and offensive. It appears, as a rule, within a 
 week or two of the infliction of the injury, and it is rarely 
 relieved by any treatment other than removal of the for- 
 eign body; after that it disappears at once. 
 
 4. Proneness to Chill. On making inquiry into the 
 clinical history of patients in whose lung a foreign body is 
 retained, I have been struck by their frequent reference to 
 attacks of "colds" or "chills." In these attacks, which 
 last only a few days, the patient feels cold, shivers, has 
 "goose flesh," feels miserable, and keeps huddled over a
 
 THE SURGERY OF THE CHEST 209 
 
 fire. The dyspnoea and cough are a little worse, slight 
 haemoptysis may occur, and exertion is avoided. The 
 temperature is raised for two or perhaps three evenings to 
 101 or 102. The little attack soon passes off, and the 
 patient feels himself again. These recurrent waves of 
 infection for that is what they are show that the lung is 
 not always tolerant of the presence of a septic foreign 
 body. 
 
 5. Palpitation. A number of patients have complained 
 of severe palpitation, and of pain over the heart, as well as 
 dyspnoea upon exertion ; and several of them felt reluctant 
 to he upon the affected side. Irregularity of the pulse has 
 never been noted, nor intermission. 
 
 In a very few cases there have been complaints of di- 
 gestive discomforts, pain and flatulence after food, eructa- 
 tion chiefly due to air-swallowing, and constipation. In 
 the worst of the cases there were many adhesions of the 
 lung to the diaphragm. 
 
 C. OPERATIONS FOR THE REMOVAL OF PROJECTILES 
 FROM THE CHEST 
 
 GENERAL PRINCIPLES AND DETAILS 
 
 The subject of thoracic surgery is one which, before the 
 war, had been made difficult by the cumbersome methods 
 employed. The fear of collapse of the lung when pneumo- 
 thorax occurred was present in the minds of most surgeons, 
 and was a powerful deterrent. The dread of pneumo- 
 thorax was in truth the great inhibitory influence hinder- 
 ing the development of thoracic surgery. In the belief 
 that it was necessary to prevent this, Sauerbruch and 
 others in Germany, and Willy Meyer in New York, had 
 devised and employed positive-pressure apparatus for
 
 210 ESSAYS ON SURGICAL SUBJECTS 
 
 anaesthesia, and negative-pressure chambers in which the 
 trunk of the patient and the operation team were sta- 
 tioned during the whole of the procedures conducted upon 
 an opened thorax. 
 
 There was, however, abundant evidence to show that 
 the fear of pneumothorax was greatly exaggerated. For 
 many years past I have been accustomed, in performing 
 operations upon the kidney for stone or for removal of that 
 organ, to begin by excising the last rib in order to obtain 
 more room, and in order also to prevent undue dragging 
 upon the pedicle of the kidney. In, possibly, a dozen of 
 such cases I have wounded the pleura and have heard the 
 air enter freely into the chest. No disabih'ty or distress 
 followed, and I looked upon the misadventure as rather a 
 flaw in the artistry of the operation than a matter of sur- 
 gical importance, a rebuke to my skill rather than a risk 
 to the patient. Similarly, in operating upon recurrent 
 local growths in cases of carcinoma of the breast, I have re- 
 moved portions of the chest wall and, by mishap or delib- 
 erate intention, have wounded the pleura. Again no 
 harm followed. It is well known that Bazy, of Paris, had 
 spoken of the safety of open operations on the chest for 
 years before the war; and had derided the supposed diffi- 
 culties or dangers following the free entry of air into the 
 pleura, provided always that there was no myocardial 
 disease. 
 
 All these experiences and opinions have been abun- 
 dantly confirmed by the knowledge we now have of chest 
 sjirgery in the late stages of gunshot wounds. The entry 
 of air into the cavity of the pleura has produced one effect 
 only, a temporary quiescence or cessation of the respira- 
 tions. Before opening the pleura we have taken pains to 
 obtain a deep anassthesia. Air is allowed to enter the
 
 THE SURGERY OF THE CHEST 211 
 
 pleura slowly through an incision which, small at first, is 
 subsequently freely enlarged, so as to allow of the easy 
 entry of the hand into the chest cavity. The lung at once 
 collapses, but the degree of collapse is, as a rule, slight 
 compared with our expectations. It is not the degree of 
 collapse seen in the post-mortem room. Such as it is, it is 
 entirely to the advantage of the surgeon: it allows his 
 manipulation to be more freely conducted within the 
 chest; it enables him to reach all parts of the lung more 
 easily; and it permits of the withdrawal of every part of 
 the lung except the hilum from its ordinary position up to 
 the anterior wound, and even outside the chest wall. I 
 can imagine only one serious risk in the making of an open 
 pneumothorax, and that is the wounding of the opposite 
 pleura and the production of a double pneumothorax. 
 That has never occurred in any of my cases, and in opera- 
 tions upon the lung is, I suppose, an impossible catas- 
 trophe. 
 
 If, however, the oesophagus were being in part excised, 
 the danger would be a real one and need to be kept in 
 mind. Emboldened by my experience in these cases of 
 gunshot wound of the chest, and on the urgent demand of a 
 patient, I recently excised a growth including 3 in. of the 
 oesophagus. The growth lay below the arch of the aorta, 
 to which, and to the posterior surface of the left auricle, it 
 was firmly adherent. I excised the 7th left rib and divided 
 the 6th, 5th, 4th, and 3rd ribs posteriorly, and, introducing 
 Balfour's abdominal retractor, spread the ribs apart very 
 widely. I laid the pleural cavity open freely and obtained 
 a wonderful view of the heart, aorta, great vessels arising 
 from it, trachea, oesophagus, and lung. The actual opera- 
 tion for removal was then made very easy ; but remember- 
 ing that the relations of the oesophagus in that region are
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 more intimate with the right pleura than with the left, 
 the most scrupulous care was taken to avoid any opening 
 of the opposite pleural cavity. 
 
 The Separation of the Pleural Adhesions. The num- 
 ber, density, and strength of the adhesions found in the 
 pleural cavity vary within the widest limits. They may 
 be few, thin, and light, separating at the gentle touch of 
 the finger; or they may be of the utmost density. I have 
 several times had to dissect off from the surface of the lung 
 thick masses of lymph, as solid as the felt of which a flat- 
 foot pad is made. In such a case it is interesting to see the 
 lung expanding little by little as it is freed from the dense 
 adhesion which has clearly been compressing it. 
 
 In my earlier cases I felt that the indication for opera- 
 tion was the presence of the foreign body in the lung, and 
 that the removal of that foreign body was the sole purpose 
 of the operation to be performed. By degrees I came to 
 believe that the removal of the projectile was only a part, 
 and perhaps not always the most important part, of the 
 operation. The adhesions encountered were so consid- 
 erable in many instances that I became persuaded their 
 presence alone would account for most of the disabilities 
 of which the patient complained, and that their separation 
 or removal would alone give relief to all distress. But 
 realizing the frequency of infection present on the foreign 
 body and the occasional presence of fragments of clothing 
 which were always very offensive, I concluded that the 
 purpose of the operation was a dual one, and that there 
 was perhaps little to choose between the relative impor- 
 tance of the two intentions. 
 
 The separation of dense adhesions following perhaps 
 upon a haemothorax or upon an empyema is by no means 
 free from serious consequences, especially if the foreign
 
 THE SURGERY OF THE CHEST 213 
 
 body, which at last is reached and removed, is infected. 
 In five of my cases empyema followed such a procedure: 
 in all the foreign body was infected, in all there was 
 haemorrhage into the pleural cavity after the operation, 
 and aspiration of this was in the first place necessary. 
 The lesson to be learnt from this experience is that, in all 
 cases requiring the removal of dense adhesions, the great- 
 est care should be taken to secure perfect haemostasis be- 
 fore the chest is closed. We have only a slight experience 
 of draining such cases for one or two days, but such as it 
 is it suggests that, where oozing cannot be completely 
 checked at the time of operation, drainage gives safety and 
 comfort. The continuance of the tube for longer than, 
 say, thirty-six hours is probably harmful. Our general 
 practice has been firmly and continually opposed to drain- 
 age wherever possible. 
 
 The dual intention of the operation is shown also by 
 a consideration of those cases in which the projectile has 
 passed completely through the thorax, or has passed 
 through the pleural cavity and lies embedded in the chest 
 wall. In such cases a high degree of respiratory embarras- 
 ment, due to pleural adhesions the result of an old haemo- 
 thorax, may be present. The opening of the chest cavity 
 to free the lung from the thick membranes which cripple 
 its action is then certainly desirable, though no foreign 
 body require to be removed. 
 
 Anaesthesia. The question of the anaesthetic to be 
 used required, of course, very anxious consideration. We 
 considered first the possibility of performing all the opera- 
 tions under local infiltrative anaesthesia, or under the para- 
 vertebral regional anaesthesia which I have seen used so 
 successfully by Pauchet, of Amiens. Chloroform here, 
 as elsewhere, I refused to sanction. The obvious dangers
 
 2/4 ESSAYS ON SURGICAL SUBJECTS 
 
 are great, and its remote dangers in all cases not yet suffi- 
 ciently realized. For years I have abandoned its use, and 
 I saw no reason to try it in cases of this kind. 
 
 Ether has proved so satisfactory in all my work that I 
 determined, if possible, to retain it here also, with or with- 
 out gas, and oxygen-ether is universally applicable. Dr. 
 Adamson has acted as anaesthetist at every operation, and 
 she has kindly written the following brief account of her 
 method and experience: 
 
 Method of Anaesthesia for Intrathoracic Operations. 
 The method of obtaining a satisfactory anesthesia for 
 intrathoracic operations involved very little difficulty 
 after the first three or four cases. The first cases were 
 frankly experimental from the point of view both of the 
 depth of anaesthesia required and of the means by which 
 this might be brought about. The method has now been 
 stereotyped in its essential points, and only calls for varia- 
 tions to meet minor differences in individual patients: the 
 patients have all been young men from 19 to 34 years, in 
 sound condition resulting from military training, and im- 
 mediately before operation have been free from any infec- 
 tion giving rise to a high temperature. Many of them 
 have required a large amount of anaesthetic. 
 
 The anaesthetic used for all the cases has been ether, 
 administered through a Hewitt's wide-bore apparatus. 
 This has been chosen for the following reasons: the ether 
 has acted to a certain extent as a respiratory stimulant in 
 cases which have had to carry on their whole respiratory 
 function with one lung only ; and for the convenience of the 
 operator the depth of the anaesthesia has needed to be so 
 great that chloroform administered to such a degree would 
 have been extremely dangerous.
 
 THE SURGERY OF THE CHEST 215 
 
 Having chosen ether as the more suitable anaesthetic, 
 and considering it unwise to give any chloroform at all, it is 
 obviously impossible, with this class of patient, to induce 
 a satisfactory anaesthesia by the open method. The 
 closed inhaler has been used throughout the series of cases. 
 A positive-pressure apparatus was not used, as the surgeon 
 wished for a collapsed lung. 
 
 In the earlier cases nitrous oxide gas was used to begin 
 the induction, but has been discontinued because of a 
 tendency to persistent cyanosis which appeared in some of 
 the patients who were already the subjects of varying de- 
 grees of dyspnoea. 
 
 Before coming to the theatre the patients are given a 
 preliminary hypodermic injection of morphine gr. , sco- 
 polamine gr. y^, and atropine gr. y^, half an hour before 
 the induction of general anaesthesia. This preliminary in- 
 jection overcomes the agitation some of the patients show 
 at the prospect of what is to them an alarming operation, 
 and it also overcomes any trouble from excessive salivary 
 or bronchial secretions. 
 
 Induction is begun with the Hewitt's apparatus with- 
 out the bag, the proportion of ether being increased from 
 nothing to the full strength possible. When this point is 
 reached, and when the patient is breathing easily, the bag 
 is fixed to the apparatus and used until the completion of 
 the operation. For most patients the anaesthesia pro- 
 duced by this method alone is insufficient, and then the 
 strength of ether vapour is increased by placing the bag in 
 a bowl of hot water and also by surrounding the ether con- 
 tainer with a swab wrung out of hot water. With this 
 added help it has practically always been possible to ob- 
 tain the required depth of anaesthesia, however powerful
 
 216 ESSAYS ON SURGICAL SUBJECTS 
 
 and resistant the patient, provided this has been carried 
 out before the plenral cavity is opened. 
 
 From the outset, anaesthesia is pushed to a considerable 
 depth, allowing of complete muscular relaxation, and for a 
 few minutes before the pleural cavity is opened the end of a 
 flexible rubber tube connected with an oxygen cylinder is 
 introduced under the edge of the face-piece of the inhaler 
 and a gentle stream of oxygen allowed to pass along it. 
 The face-piece is then kept sh'ghtly tilted to prevent over- 
 distention of the bag with oxygen, but it is not removed 
 periodically to give the patient a breath of fresh air as is 
 usual when employing a closed inhaler for other operations. 
 
 At the time of the incision of the pleura the patient is 
 deeply anaesthetized, breathing evenly and slowly, and his 
 colour is bright red from the inhalation of an excess of 
 oxygen. Directly the pleural cavity is opened, the lung, 
 if free from adhesions, collapses, and the patient stops 
 breathing. The period of apncea varies from a few seconds 
 to one or two minutes. The pulse remains regular, and 
 usually unchanged in rate. In a few cases the rate has 
 been increased by ten to twenty beats a minute for a few 
 minutes and has then returned to its previous rate. The 
 patient's colour has remained bright red. 
 
 Breathing recommences at about the previous rate, 
 but the range of respiration is extremly shallow, and re- 
 mains so until the end of the operation. For this reason it 
 is essential that the opening of the pleural cavity shall be 
 delayed until a satisfactory deep anaesthesia is obtained, as 
 it has been found quite impossible to repair the omission 
 later. The stream of oxygen is continued during the 
 whole operation, and may need to be slightly increased for 
 a short time after the resumption of respiration following 
 the period of apncea. The anaesthesia produced in this
 
 THE SURGERY OF THE CHEST 217 
 
 way is sufficient to allow of the necessary manipulation of 
 the lung and freeing of adhesions, the delivery of the lung 
 through the wound to allow of thorough examination, and 
 the stitching of any bleeding wound in the lung or its root. 
 In cases which have involved manipulation of the heart 
 there has been a temporary weakening of the pulse corre- 
 sponding to any definite pressure on the heart. There has 
 been no irregularity or missing of heart-beats noticed from 
 this cause. 
 
 At the end of the operation the patient's colour is usu- 
 ally bright red, the respirations are still shallow and regu- 
 lar, and the pulse is of the quality that it was at the begin- 
 ning. In most cases the administration of oxygen has 
 been stopped directly the pleural cavity has been closed, 
 and the patient has remained comfortable and of good 
 colour on his return to bed. In a few cases the respira- 
 tions have been too shallow to maintain a satisfactory 
 oxygenation of the blood, and the patient has become 
 markedly cyanosed and his pulse has begun to fail. This 
 unsatisfactory condition has been remedied by administer- 
 ing small quantities of oxyg6h at intervals, whenever the 
 patient's colour becomes in the least blue. 
 
 The only real difficulty in connection with the anaes- 
 thesia for intrathoracic operations is in obtaining a suffi- 
 cient depth in the patients who require a large amount of 
 anaesthetic to produce even unconsciousness. If the pa- 
 tient is insufficiently anaesthetized he is the subject of a 
 most troublesome cough and straining each time an at- 
 tempt is made to touch the lung. This greatly hampers 
 the operation, and, owing to the shallow respiration and 
 consequent small amount of anaesthetic inhaled when the 
 pleural cavity is opened, it is practically impossible to 
 deepen the anaesthesia at this stage.
 
 218 ESSAYS ON SURGICAL SUBJECTS 
 
 On this account it should be emphasized that it is 
 essential to secure a complete anaesthesia without cyanosis 
 before the pleural cavity is opened, even if it leads to ap- 
 parent delay in the operation. 
 
 The Use of jt-Rays During Operation. The perform- 
 ance of operations for the removal of foreign bodies, in all 
 parts of the body, under the x-rays has been almost uni- 
 versally practised in France, where special operation tables 
 have been devised, and where the radioscopic "bonnet" 
 has been perfected. Comparatively little use has been 
 made in the British Army of such methods. Various criti- 
 cisms of an a priori kind have been brought against the 
 French methods. It is said that the operator does not 
 know where his instrument is going when it is pushed 
 directly through the tissues of the limb or the chest, from 
 the surface to the foreign body; that vessels or nerves may 
 be encountered unwittingly and seriously damaged, with 
 grave consequences; that the foreign body, even when 
 reached, may not be easily grasped ; and that the forcible 
 and rough withdrawal of a foreign body, perhaps heavily 
 infected, through sound tissues may be the cause of an 
 acute recrudescence of sepsis in the wound. It is said 
 that such operations are "groping in the dark," and that a 
 method is "unsurgical" which does not allow the operator 
 to see what he is doing and where he is going. I confess 
 that I feel a certain sympathy with all these objections; 
 but they are, I now realize, quite invalid. The success, not 
 of a few cases but of many thousands, has shown, I think 
 indisputably, that the screen methods are, on the whole, 
 and in properly chosen cases, safer than the open methods, 
 and that their after-consequences are at least as tranquil. 
 To the criticism that the operations are "blind," the ex- 
 pert French surgeon replies that, on the contrary, under the
 
 THE SURGERY OF THE CHEST 219 
 
 screen he sees exactly what he is doing, and that, when the 
 foreign body has been accurately localized, he knows pre- 
 cisely what structure he may meet, and what structure he 
 must avoid. And he will point to a very long series of 
 cases to show that the fear of infection of the track along 
 which the metal is withdrawn is excessively small. It is 
 admitted, of course, that the methods have not a universal 
 application. There are regions, like the heart or the hilum 
 of the lung, that must always be approached by the open 
 method. And there are projectiles so large that they can- 
 not be withdrawn from the chest in the narrow space be- 
 tween two ribs. The work needs a special brief education ; 
 but the fact that the technique is by no means especially 
 difficult is shown by its wide adoption by the army sur- 
 geons in France, and by the success which has attended it 
 in all hands. 
 
 Whatever operation is practised upon the chest, the 
 most accurate localization of the foreign body by x-rays is 
 desirable; and the condition of the lung, the presence of 
 pleural adhesions, and the range of movement in the dia- 
 phragm, should all be investigated. My colleague, Dr. 
 H. B. Scargill, who has conducted all the radiological 
 examinations in my cases, has kindly written the follow- 
 ing brief note. 
 
 RADIOLOGICAL EXAMINATION. This resolves itself 
 into three parts: 
 
 1. The Localization of the Foreign Body Should be as 
 Accurate as Possible. It is advisable to mark the position 
 of the foreign body on both anterior and posterior surfaces, 
 and to indicate the distance of the foreign body from each. 
 
 The radiograph should always be taken from the sur- 
 face nearer to the foreign body. The depth from the sur-
 
 220 ESSAYS ON SURGICAL SUBJECTS 
 
 face can be ascertained by any of the usual methods. It is 
 advisable to make observations from the anterior and 
 posterior surfaces as a means of checking the result ob- 
 tained. 
 
 2. The Screen Examination of the Chest. If the metal 
 moves downwards on deep inspiration, it must be in the 
 lung, or embedded in the diaphragm. 
 
 If in the root of the lung the movement is downward, 
 but is very slight indeed. 
 
 If the movement is upward on inspiration, the metal is 
 either (a) in the chest wall, or (6) in a portion of the lung 
 which is firmly adherent to the chest wall and can only 
 move with the chest wall. 
 
 3. The Examination for Adhesions of the Lung and 
 Chest Wall. In the lower part of the chest, the movement 
 of the arch of the diaphragm on the affected side is most 
 important as an indication of the degree of expansion of 
 the lung. 
 
 Around a part of the lung which is adherent to the chest 
 wall there is generally patchy opacity to be seen, due to 
 thickening of the pleura. In some cases the lung and 
 pleura may appear quite translucent, and yet at operation 
 there may be found very firm adhesions. 
 
 Adhesions can only be seen as opacities when there is 
 thickening of the pleura of long standing. 
 
 INDICATIONS FOR OPERATION 
 
 So far as our present knowledge goes, the indications 
 for operation seem to be: 
 
 1. The Continued Presence of Subjective Symptoms 
 A full account of these, as seen in my own cases, has been 
 already given. In all the cases I have dealt with by opera- 
 tion the complaints have been real, and the distress, in the
 
 THE SURGERY OF THE CHEST 221 
 
 patient's opinion, has been ample warrant for his submis- 
 sion to an operation, the perils of which I did nothing to 
 belittle. It must be admitted that in many patients a 
 degree of apprehension with regard to their condition 
 exists, and that consequently their subjective phenomena 
 may lack nothing in descriptive detail. But an increasing 
 experience has shown that the x-ray disclosures and the 
 conditions found at operation often account for the pres- 
 ence of symptoms which had been ascribed to "functional" 
 causes. The presence of thick masses of adhesions, which 
 revealed little or no evidence on auscultation or percussion 
 especially adhesions to the diaphragm will account for 
 many legitimate complaints of pain in the mediastinal 
 regions, or in the abdomen. It is not so much the mere 
 presence of a foreign body in the lung that should be con- 
 sidered, but rather the various changes in the lung and in 
 the pleura which result from the original injury, and which 
 are chiefly the cause of symptoms and chiefly in need of 
 relief. 
 
 2. The Conditions of the Foreign Body and of the Lung 
 Surrounding It. The foreign body induces certain changes 
 in the parts of the lung in its immediate neighbourhood. 
 These are described elsewhere. A complete investment of 
 the foreign body by a fibrous covering is rare. Only once 
 have I seen a piece of metal so closely covered on all sides 
 as to be isolated from lung tissue and, so far as could be 
 judged, incapable of inflicting further injury on the paren- 
 chyma. Conditions which are those of perfect and perma- 
 nent tolerance of a foreign body are, therefore, extremely 
 rare. Around the foreign body the physical conditions of 
 the lung, however altered, are rendered more, rather than 
 less, likely to be made active by the presence of an irritat- 
 ing or infected piece of metal or of clothing. If we take
 
 222 ESSAYS ON SURGICAL SUBJECTS 
 
 into account the character of the foreign bodies retained, 
 the physical properties of the tissue in which they are held, 
 the incessant movement of the chest, the high degree of 
 physiological activity present in the lung, and the number 
 and size of the vessels in the chest and in the lung tissue, 
 it is probably, as a rule, wiser to advise removal of the 
 foreign body than to sanction its retention. 
 
 3. The Conditions of the Pleural Cavity. In many cases 
 that I have operated upon pleural adhesions were present 
 in a degree that alone would cause a restriction of the ac- 
 tivities of the lung. In such cases the measurements of 
 the chest on the affected side are smaller; dullness may be 
 present in some degree ; and there is deficient entry of air 
 into the chest. The sinking in of the chest wall, the col- 
 lapse of the lung, and the pulling over of the whole medias- 
 tinum, are results of the pleural injury and the patholog- 
 ical conditions subsequently developed, and are causes of 
 the respiratory and other difficulties of which an account 
 is given elsewhere. 
 
 It is important to know to what extent these conditions 
 can be relieved by operation. Speaking broadly, two types 
 of operations are performed in such cases the method of 
 Petit de la Villeon, and the open method. In the former, 
 nothing is done to alter the physical conditions within the 
 chest cavity other than the removal of the foreign body. 
 In the latter, all adhesions are separated, masses of lymph 
 dissected off the lung and the diaphragm, and a consider- 
 able attempt made to cause a return of the conditions to 
 the normal. How far such efforts are successful is, with 
 the evidence at my disposal, a matter of doubt. If there 
 has been an empyema before the operation, I think the 
 conditions in my own cases have not been improved. 
 This may possibly be due to a too early operation in which
 
 THE SURGERY OF THE CHEST 223 
 
 infection has been freshly aroused, here as elsewhere, by 
 precocious interference. If adhesions have been extensive 
 and dense, their removal has certainly given increased free- 
 dom to the action of the lung. The records of my cases 
 show that benefit has almost always resulted in such cases. 
 Improvement does not occur in the same degree or so 
 rapidly if no operation is done; for in patients whom I 
 have kept under observation for months before operation, 
 the change in the condition of the chest on examination, 
 clinically or by x-rays, and the improvement in their sub- 
 jective disturbances, has been either absent or exceedingly 
 small. Open operation may therefore be said to be justi- 
 fied by its results. 
 
 METHODS OF OPERATION 
 
 The methods which have been practised for the re- 
 moval of foreign bodies from the chest will be considered 
 in the following order: (1) Method of Petit de la Villeon; (2) 
 Method of Marion; (3) The open method of Duval; (4) Opera- 
 tions upon the hilum of the lung; (5) Operations upon the 
 mediastinum. 
 
 1. Method of Dr. Petit de la Villeon. The operation 
 consists in the introduction, through a very small incision 
 made between two ribs, of a special pair of forceps, with a 
 blunt end and long parallel blades on the one side of the 
 hinge, and short "crocodile-jaw" blades on the other. The 
 position of the foreign body is very accurately determined 
 by the x-ray. The operation is performed under the x-ray 
 and with the aid of the screen. A preliminary injection of 
 morphine is given and a light general anaesthesia induced. 
 Petit de la Villeon uses chloroform. The forceps are in- 
 troduced from the axillary side, the incision to admit them 
 being made along the upper border of the rib, so as to
 
 224 ESSAYS ON SURGICAL SUBJECTS 
 
 avoid vessels, and are guided by the image on the screen 
 and directed towards the known position of the foreign 
 body. The progress of the instrument is slow and gentle, 
 and continues until the image of the tip of the forceps and 
 of the foreign body coincide. If the entry has been ex- 
 pertly made the contact will then be felt; the metal is 
 grasped by the \vide opening of the "crocodile-jaw" 
 blades, and is slowly and steadily withdrawn. Nothing 
 remains but to close the skin wound by a single stitch. 
 The penetration of a blunt forceps into the lung tissue does 
 no damage. It ruptures no vessels ; it does no injury to the 
 delicate tissues of the lung ; it seems to cause a separation 
 of the tissues rather than a destruction of them. The ex- 
 perience of recent wounds of the lungs in this war has 
 shown how very tolerant of injury they are, and how few 
 are the symptoms produced by the slighter degrees of 
 trauma. It is not then surprising to hear that a blunt 
 instrument may be gently pushed through the lung sub- 
 stance without giving rise to any real danger. The with- 
 drawal of a foreign body might be attended by more se- 
 rious injury, especially if there were many sharp points and 
 rough surfaces; these, however, do not inflict much injury, 
 if any, if the jaws of the forceps grasp and include the for- 
 eign body in their embrace. Such damage as is caused 
 would be enhanced in severity if the metal chanced to be 
 infected by one or more organisms, which we know will re- 
 main potentially active in the lung for years. But sup- 
 positions and fear must yield to experience; and this has 
 given abundant proof, in the hands of all, that the risks 
 of injury are almost negligible. The mortality has been 
 found to be extremely small, far less than by any other 
 operation practised. The post-operative course is so 
 smooth and devoid of incident as to excite the frank as-
 
 THE SURGERY OF THE CHEST 225 
 
 tonishment of all who see the method practised for the 
 first time. The functional recovery is said to be at least 
 as good as that which follows the open operations ; and is 
 obtained at less risk and less cost in respect of suffering 
 and duration of convalescence. 
 
 There are certain centra-indications to the method: 
 
 (a) Proximity of the Foreign Body to the Hilum of the 
 Lung. One of the few fatalities in the large series of 
 cases operated upon by Petit de la Villeon occurred as the 
 result of haemorrhage after extraction of a piece of metal 
 from the hilum. He, and every other surgeon, now agrees 
 that for all retained projectiles in this position an open 
 operation is necessary. It is imperative that the work to 
 be done should be carried out under open inspection, and 
 that steps should be taken to avoid laceration of the large 
 and numerous vessels in the root of the lung, and to arrest 
 such hemorrhage as occurs either by suture or, as Petit 
 de la Villeon prefers, by packing with gauze for two or 
 three days. 
 
 (b) Proximity of the Foreign Body to the Heart. In one 
 of his cases reported in Bull, et Mem. Soc. de Chir. de Paris, 
 1918, p. 577, Petit de la Villeon describes the projectile 
 as "appearing to be included in the wall of the left ven- 
 tricle of the heart." It was extracted by his method, the 
 forceps passing through the entire thickness of the lower 
 lobe of the left lung. In another case some fibres of heart 
 muscle were found on the missile after removal. In his 
 most skilful hands the method does not appear to have 
 presented unusual difficulties or serious dangers; but it is 
 nevertheless one to be condemned. In all cases where the 
 projectile is adherent to the surface of the heart, or in 
 which the lung is so adherent to the pericardium, and this 
 membrane to the heart, that it is impossible to say how 
 
 15
 
 226 ESSAYS ON SURGICAL SUBJECTS 
 
 close the connection between the missile and the heart may 
 be, the open operation alone should be practised. 
 
 (c) The Size of the Projectile. The great majority of 
 the foreign bodies lodged in the parenchyma of the lung 
 are of so small a size as to allow of their easy extraction 
 between the ribs. If the projectile is large, a piece of rib 
 may be resected, or raised, and the remainder of the opera- 
 tion conducted in the usual manner. But even then the 
 damage done to the lung by the forcible dragging through 
 its tissues of a large solid body must be taken seriously into 
 account. For large projectiles the open operation is either 
 the only possible method, or the safer. 
 
 (d) Suppuration Round the Projectile. This can gener- 
 ally be determined by the radiologist. When it is evident 
 that a small abscess surrounds the foreign body, or that 
 it is encased in a hard sclerotic mass, it is unwise to attempt 
 the removal by this method. It is impossible to say 
 whether the pus which lies on all sides of the missile is 
 heavily infected or no. But it is well to take no risks. 
 The removal of the foreign body in all such cases should be 
 done under full inspection, so that an adequate cleansing 
 of the infected cavity may be secured. 
 
 (e) The Presence of Other Foreign Bodies than that Shown 
 on the Screen. It is not often that pieces of clothing are 
 found with the projectiles in the parenchyma of the lung. 
 I know no explanation for this: but it is, in my experience, 
 far less frequent to find debris of clothing in the lung than 
 in the limbs, when pieces of metal are being removed. 
 The danger of leaving behind a piece of cloth is therefore 
 very slight, and the subsequent clinical history of a large 
 number of cases shows that the risk is one that need hardly 
 be considered. Petit de la Villeon believes that in many 
 cases he removes not only the foreign body but its cap-
 
 THE SURGERY OF THE CHEST 227 
 
 sule, and any other foreign body included in it. Such 
 an experience must, I am sure, be exceedingly infrequent. 
 
 The essential circumstance for the successful extrac- 
 tion of the projectile by this method is its mobility with the 
 lung. This is indicated by the x-ray ; the shadow of the 
 foreign body should move downwards concomitantly with 
 the diaphragm. The exception is in the case of foreign 
 bodies in the apex of the lung, where the range of move- 
 ment is slight or absent. This freedom of motion indi- 
 cates that the metal is not embedded in a mass of dense 
 adhesions outside the lung, extrication from which would 
 involve gross and heavy-handed measures. The benig- 
 nity of the operation is remarkable. It is rare for a patient 
 to be incapable of discharge from hospital in eight or ten 
 days. 
 
 It has often been asserted that the method is a "blind" 
 one; that the surgeon is "groping in the dark"; and that it 
 is easy to lose one's way and to be compelled to pierce the 
 lung in several directions until contact with the metallic 
 foreign body is made. All these things depend upon the 
 surgeon. To render it not a "blind" but an open method 
 a "clairvoyant method" it is necessary for the operator 
 to become practised in screen examinations, and to make 
 himself an adept in the removal of projectiles from the 
 limbs. As Petit de la Villeon says, an apprenticeship is 
 necessary. This is hardly an objection, or if it is, it has a 
 wide application. The method has on many occasions 
 been controlled in this way: the small external incision 
 has been made, the lung pierced, the forceps left in situ, 
 and the chest opened to remove a foreign body whose 
 fibrous casing has been dense, or whose situation in the 
 diaphragm has made withdrawal difficult. An inspection 
 of the lung has shown only a slight bruise at the point of
 
 22S ESSAYS ON SURGICAL SUBJECTS 
 
 entry of the forceps, and "not a drop" of blood has been 
 seen to issue from the path made in the lung. 
 
 There are times when a little air escapes into the pleural 
 cavity by the side of the forceps. This is of no account. 
 We know by long experience how little is the harm done 
 by a pneumothorax so caused, as, for example, in operation 
 on the kidney when the last rib is removed. Robineau, 
 indeed, holds the opinion that it may even make the opera- 
 tion easier. He finds also that when the method is prac- 
 tised as an open operation, in the circumstances just men- 
 tioned, the movement of the forceps within the lung is al- 
 ways free, causes no haemorrhage, never lacerates the 
 lung, but allows it to slip forwards and backwards along 
 the forceps with great ease. 
 
 The most alarming consequence which has followed 
 upon this method is haemoptysis. In some degree this oc- 
 curs in the majority of cases; in serious degree, very seldom. 
 Margins records one case in which the haemorrhage was 
 extremely serious though not fatal. 
 
 An occasional rise of temperature occurs; and a local- 
 ized patch of consolidation may be found. In one case P. 
 Duval lost a patient from double pneumonia. A serous 
 effusion of slight degree into the pleural cavity is not infre- 
 quent. The evidences of it usually disappear within four 
 or five days. 
 
 2. Marion's Method. This consists in resection of one 
 rib in front, usually the 4th or 5th. When the pleura is 
 exposed and the lung is visible underneath, a curved 
 Reverdin needle is passed through the pleura into the lung, 
 out through the pleura again, and the stitch tied. A series 
 of such stitches fix the lung firmly to the parietal pleura. 
 When such fixation is thought to be complete, the pleura 
 and lung together are incised. Air does not enter the
 
 THE SURGERY OF THE CHEST 229 
 
 pleural cavity ; that is to say, no pneumothorax develops. 
 From the incised lung air and blood escape. A finger is 
 pushed into the wound, and the foreign body felt and ex- 
 tracted with the finger; or a Kocher's forceps, or other in- 
 strument, is passed into the lung until the foreign body is 
 felt, seized, and then extracted. Marion then passes a 
 strip of gauze into the wound in the lung and allows this to 
 remain for a few days. The parietal wound is closed 
 round the gauze. 
 
 I can see little advantage in this method. The fear of 
 pneumothorax is an exaggerated fear. The one reason for 
 its adoption may be this, that in cases of infected foreign 
 bodies the risk of conveyance of the infection is limited to 
 the small track through the lung and to the parietal wound : 
 it does not affect the cavity of the pleura. 
 
 The objection has been brought against the method 
 that it creates a solid mass of adhesions fixing the lung to 
 the parietal pleura. That is true ; but some degree of ad- 
 hesion of the lung no doubt occurs to every parietal wound 
 in the ordinary open operation, especially when the pleural 
 coaptation has been imperfect, as it often is. Some sur- 
 geons, R. Oliver, of Lyon, for example, speak enthusiastic- 
 ally of this method. (Lyon Chir., 1918, xv, 351.) 
 
 3. The Open Operation of Duval. The operation I 
 have performed in my cases a slight modification of 
 Duval's is the following: An incision is made exactly in 
 the line of a rib (Fig. 9), following its curve, from the 
 edge of the sternum outwards, for about 5 inches. As a 
 rule the 4th rib is chosen. If the projectile is in the apex 
 of the lung the 3rd rib may guide the line of incision ; if the 
 projectile is at the lower part of the chest the 5th rib is 
 selected. The room given for the introduction of the 
 hand is greater, the lower the incision is made. The in-
 
 230 ESSAYS ON SURGICAL SUBJECTS 
 
 cision cuts through the skin, subcutaneous tissue, and pec- 
 toralis fascia, and exposes the fibres of the pectoralis 
 major muscle. A pair of forceps is pushed through the 
 fibres of the muscle until it touches the rib ; the blades are 
 opened and the muscle is split, and the separation is 
 widely made from end to end of the original incision. The 
 pectoralis minor is then exposed, and may be split in the 
 same manner, or cut away until the outer surface of the 
 rib is seen. All vessels which bleed, and there are many, 
 are carefully ligatured, for a very dry wound is essential. 
 
 The rib and costal cartilage are now well exposed. 
 Through the periosteum two incisions are made close to 
 the upper and lower edges of the rib, and from them the 
 periosteum is stripped upwards and downwards and from 
 the posterior surface. The periosteum which lies between 
 the two incisions is not separated from the rib, but re- 
 mains attached to it through all the stages of the operation. 
 
 As soon as the periosteum is freed from the posterior 
 surface for half an inch, the periosteal elevator of Doyen is 
 slipped round the rib, and pushed backwards towards the 
 axilla and forwards to and along the costal cartilage, until 
 a length of about 5 inches is cleared. Here and there a 
 little help may be needed with the knife or scissors to make 
 the way easy for the instrument. The costal cartilage is 
 now divided by two incisions meeting at a point (Fig. 10) ; 
 this allows the divided ends to dovetail together when the 
 operation is nearing completion. When the cartilage is 
 divided, a gauze strip is passed underneath the rib, which 
 is lifted gently upwards and outwards (Fig. 11). 
 
 In young patients the elasticity and suppleness of the 
 rib are remarkable. It is quite easy to raise the bone out 
 of the way throughout the operation and then to replace it. 
 The third rib does not lift so easily as the lower ribs, being
 
 THE SURGERY OF THE CHEST 231 
 
 shorter and therefore more resistant. In four cases (three 
 of the 3rd rib) the bone has fractured as the result of the 
 drag made on it. In three cases it was replaced and united 
 firmly. When the rib is elevated, the periosteum is seen 
 as a thickening of the pleura exposed in the wound. 
 
 Through periosteum and pleura a small incision is 
 made, with the result that, in the absence of adhesions, air 
 slowly enters the pleural cavity, and the lung begins to 
 collapse. It is, I think, important to allow of the slow 
 development of the pneumothorax ; a sudden collapse of 
 the lung might cause a little respiratory embarrassment. 
 If air enters very slowly, the regular breathing is hardly 
 disturbed for more than a few seconds or a minute, and the 
 operation can proceed as tranquilly, so far as anaesthesia 
 is concerned, as if it involved one of the extremities. Le 
 Fort is, I believe, alone in saying that an immediate wide 
 opening of the pleura is safer than the practice of making 
 a small incision and allowing air to enter slowly. The in- 
 cision in the pleura is then lengthened, always along the 
 line of the periosteum, until there is room for the hand to 
 pass through it. The rib-spreader is then introduced 
 (Figs. 11 and 12). Tuffier's pattern is the most easily 
 worked, and is very helpful. Separation of the ribs above 
 and below that which has been elevated is always easy 
 enough. I have never found it necessary to remove or ele- 
 vate another rib, or to divide another costal cartilage to 
 allow of more space being obtained by further displace- 
 ment of the ribs. 
 
 An inspection of the chest is now made, and note is 
 taken of any adhesions that may be found. The adhesions 
 vary to a great extent; they may be few and of the lightest 
 texture, breaking down with the gentlest handling; they 
 may be almost universal, requiring a firm effort to separate
 
 232 ESSAYS ON SURGICAL SUBJECTS 
 
 them; they may be of the utmost density, J inch in thick- 
 ness, so firm and strong that a separation with the finger 
 alone is quite impossible. I have several times had to cut 
 away, with the scissors, plates of lymph as thick as felt 
 before I could liberate the compressed lung. As such ad- 
 hesions are removed, the lung is seen to expand. It has 
 been my practice always to separate every adhesion as the 
 first part of the intrapleural stage of the operation. 
 
 I have felt, rightly or wrongly, that the restriction of 
 the free expansion of the lung by adhesions was to be con- 
 sidered as perhaps the most essential point of the opera- 
 tion. Ttye separation of adhesions, except those of the 
 toughest sort, is best carried out by the procedure of 
 "gauze stripping" which is adopted in the separation of a 
 hernial sac. On separating adhesions, cavities containing 
 old blood-clot may be found. On one occasion such a 
 cavity contained not less than a pint and a half of old 
 blood-stained fluid of the colour and consistency of thick 
 cocoa. On two occasions I have found the remains of an 
 empyema which had not been opened. These conditions 
 could not be discovered unless the adhesions were method- 
 ically and habitually separated. The adhesions bleed 
 freely, but the haemorrhage is very easily and rapidly 
 checked by the pressure of hot moist swabs, one or two 
 being left in the cavity while the operation proceeds. I 
 have sometimes felt the projectile drop into my hand as 
 the adhesions were being separated; the foreign bodies lay 
 not so much in the lung tissue as in adhesions binding the 
 two pleural surfaces together. 
 
 When the lung is freed the projectile may be sought. 
 It is easier to find a metallic foreign body in the lung than 
 in any other part of the body. When the organ is gently 
 grasped in the fingers a local hardness is felt at once. The
 
 Fig. 9. The skin incision follows the line of the fourth rib. 
 
 Fig. 10. Division of the costal cartilage.
 
 Fig. 11. Tuffier's rib-retractor introduced separates third from fifth rib 
 widely. Incision of periosteum and pleura. The rib is lifted out of the way; 
 as a rule it is raised higher than is here shown.
 
 Fig. 12. The hand introduced into the pleura to separate adhesions, etc.
 
 Fig. 13. The lung brought out on to the surface of the chest.
 
 THE SURGERY OF THE CHEST 233 
 
 part of the lung which holds the metal is then brought to 
 the surface. It is astonishing to find with what ease the 
 posterior part of the lung, for example, can be brought 
 forward to the wound, and held there while the foreign 
 body is extracted. The mobility of the lung, and the ease 
 of handling it, are very remarkable. The lung may be 
 grasped with the hand, or held lightly in the specially de- 
 vised lung forceps of Duval (Fig. 13), the grasp of which 
 is firm and delicate. When the lung containing the pro- 
 jectile has been lifted forward, the depth of the missile 
 from the surface is gauged, and steps are taken to remove 
 the metal. A pair of blunt forceps may be pushed through 
 the lung substance until they impinge on the bullet, the 
 blades are opened, and the body is grasped and gently dis- 
 entangled from the lung. Or an incision may be made 
 through the lung directly down to the body (Fig. 14), 
 which is laid bare and removed. The wound in the lung 
 is now touched with pure carbolic acid, and closed by cat- 
 gut sutures which closely approximate the pleural edges. 
 
 The condition of the lung around the retained metal 
 varies. Sometimes a small abscess cavity is discovered, 
 the pus being dried and hard; sometimes a hard fibrous 
 mass encases the metal; sometimes there is a dark-red 
 area of hepatization; quite often there is no appreciable 
 change in the density or appearance of the lung tissue. 
 
 Throughout all the manipulations the lung is handled 
 with extreme gentleness. The light hand and the tender 
 caress are as necessary in this branch of surgery as in all 
 abdominal operations, and equally repay the surgeon in 
 the quick and quiet recovery of his patients. The heavier 
 the handling of the lung, the greater appears to be the sub- 
 sequent respiratory distress from which the patient suffers. 
 
 The wound in it being closed, the lung is allowed to
 
 234 ESSAYS ON SURGICAL SUBJECTS 
 
 drop back into the chest, and pains are taken to see that all 
 the fluid is removed. Bleeding must be checked by pres- 
 sure, for the exudation of even four or five ounces on the 
 day following operation is enough to cause distress. The 
 retractor is now removed, and steps are taken to close the 
 pleural w r ound. I have rarely been able to close the pleura 
 with that perfect coaptation of the surfaces that is so eas- 
 ily obtainable in the peritoneum. The apposition is often 
 very difficult, especially at the inner end of the wound, 
 and the stitch may cut through if any special tension is 
 put upon it (Fig. 15). Help may be obtained by passing 
 one strong suture round the ribs above and below, and 
 dragging them closely together. 
 
 In early operations I wiped the lung wound over with 
 ether and left a little ether in the chest cavity. It rapidly 
 evaporated, and at the completion of the operation I as- 
 pirated the chest, drew the ether vapour away, and al- 
 lowed the lung to, expand at once. This is neither neces- 
 sary nor prudent, for the collapse of the lung helps haemo- 
 stasis, and the air left in the pleura is very rapidly ab- 
 sorbed. 
 
 The rib is now replaced: a stout catgut suture passed 
 through the costal cartilage holds the ends in apposition, 
 and this is helped very much by the dovetail incision which 
 was made to divide the cartilage (Fig. 16). Over the 
 rib the pectoralis minor muscle is sutured, and the fibres 
 of the pectoralis major are brought together by three or 
 four stitches. The pectoralis fascia is carefully sutured 
 in all its length, and finally the skin is closed by a con- 
 tinuous suture (Fig. 17). As a rule no drainage is used; 
 but in two cases in which the bleeding was free I put a 
 small drain in posteriorly for twenty-four hours, and I 
 think the patient's comfort was increased thereby.
 
 Fig. 1 l.-Position of a foreign body indicated, with the incision into the lung to 
 
 I'\|M>-.C It.
 
 Fig. l- r >- Suture of the pleura. 
 
 Fig. 16. The rib replaced and the costal cartilage sutured. 
 
 Fig. 17. Closure of the skin wound by continuous catgut or horsehair suture. 
 The scratches made on the skin ensure accurate apposition of wound edges.
 
 THE SURGERY OF THE CHEST 235 
 
 It is impossible to displace the hilum towards the sur- 
 face, and all the rather difficult and often tedious manipu- 
 lations have to be carried out inside the chest. 
 
 When the projectile is on, or in, the heart muscle, it is 
 convenient to put in one or two sutures above and below, 
 or to the sides, so as to hold the heart steady while an 
 incision is made. On one occasion only I have found an 
 isolated dried hard mass of calcareous material in the 
 lung, which was possibly a cured local tuberculosis. On 
 four occasions fragments of clothing have been found lying 
 with the projectile. 
 
 AFTER-COURSE. As a rule the after-course is simple. 
 The following complications may be seen: 
 
 Haemoptysis. This has occurred 7 times in 49 cases. 
 As a rule it is of the slightest, and causes no concern ; once 
 only have I seen a degree of haemorrhage which could be 
 assessed at 3 or 4 ounces, occurring in the first twenty- 
 four hours. 
 
 Respiratory Distress. This occurs rarely. It has only 
 been noticed in cases where a multitude of severe adhesions 
 had to be separated, and the lung rather heavily handled. 
 In 12 cases an effusion of blood or serum has been dis- 
 covered on the third or fourth day, and aspiration has 
 given a relief that was striking in proportion to the 
 amount of fluid removed. 
 
 Emphysema. Surgical emphysema has developed in 
 several cases, especially those in which a poor apposition 
 of pleural surfaces was obtained. It has twice spread 
 over the neck and face. It has always rapidly disappeared, 
 and has never been a matter of distress. 
 
 Infection of the Wound, or of the Pleural Cavity. Em- 
 pyema. In 10 cases empyema had been present before 
 operation. There were, as I have said, 12 cases in which
 
 236 ESSAYS ON SURGICAL SUBJECTS 
 
 effusion of blood occurred into the pleural cavity after 
 operation; of these, 5 developed empyema. In every 
 such case the foreign body was infected. In the remain- 
 ing 7 cases aspiration was performed, and the chest condi- 
 tion rapidly cleared up; in 6 of these cases the foreign body 
 was sterile, and in 1 infected. The infection which occurs 
 is undoubtedly the result of contamination of the wound 
 at the time of operation, for, with one exception, where 
 pneumonia occurred, the organisms recovered from the 
 wound discharges or cultivated from the opened empyema 
 were identical with those found on the projectile. These 
 organisms are coliform bacilli, streptococci, and staphy- 
 lococci. 
 
 An examination of the metal fragments removed shows 
 that a prolific growth of organisms can be cultivated from 
 them years after the infliction of the wound. The ques- 
 tion as to the wisdom of freeing adhesions in all directions 
 in the presence of an infected body will be referred to later. 
 
 4. Operations Upon the Root of the Lung. The root 
 of the lung is that part of the pedicle of the lung at the 
 region where the pleura is reflected on to it. The measure- 
 ments of the root are from above downwards about 30 mm., 
 and from before backwards about 15 to 18 mm. The 
 surface marking in front is the 3rd costal cartilage and the 
 adjacent intercostal spaces on each side; and, behind, the 
 inner end of the 5th rib and the adjacent intercostal spaces 
 on each side. In the root of the lung lie the bronchi, pul- 
 monary artery and veins, bronchial artery and veins, 
 lymphatic glands and vessels, and nerves. The glands 
 are numerous. The pedicle enters the lung at a vertical 
 notch, the hilum, about 45 to 50 mm. long and 25 mm. 
 broad. 
 
 The special considerations in connection with opera-
 
 THE SURGERY OF THE CHEST 237 
 
 tions upon the root of the lung are, chiefly, the extreme 
 vascularity of the part, its fixity, and its physical proper- 
 ties. 
 
 The number of vessels is great and their size formidable. 
 A wound of the root of the lung should be inflicted with 
 extreme caution, for if a vessel is wounded it is exceedingly 
 difficult to arrest the haemorrhage. It is almost impossible 
 to secure the vessel and to ligature it in the ordinary man- 
 ner. If a suture is passed round the vessel, it is likely that 
 other vessels will be wounded by it. For this reason 
 many of the French surgeons advise the plugging of the 
 wound with gauze, which is left in position for two or 
 three days. 
 
 One of my two fatal cases died from haemorrhage. 
 The projectile was embedded in the root of the lung. 
 After its gentle removal there was free haemorrhage, 
 which appeared to be arrested by the sutures I passed for 
 this purpose. The patient died in a few hours, and the 
 pleura was found filled with blood. The error in technique 
 was grievous, and the warning for similar cases did not go 
 unheeded. 
 
 The fixity of the root makes all operations upon it far 
 more difficult than those which engage other parts of the 
 lung. It is really surprising to find with what ease all 
 parts of the lung can be brought forward to the wound 
 made by the elevation of the 4th or 5th rib, incised, and 
 carefully sutured. The root of the lung is almost immo- 
 bile. The operator must go down to it; he cannot bring 
 the parts nearer to him. All the steps of the operation 
 can, and should be, visible to the surgeon; nothing need 
 be done in the dark ; but the remoteness and the immobil- 
 ity render all manipulations much more difficult than they 
 are elsewhere. All technical procedures at the root of the
 
 238 ESSAYS ON SURGICAL SUBJECTS 
 
 lung are made easier if the parts near the hilum are fixed 
 by the special light forceps of Duval. They not only 
 withdraw the lung from the path of the surgeon, but give 
 a stable field in which to work. 
 
 The physical properties of the root of the lung make it 
 exceedingly difficult to distinguish a bronchus from a piece 
 of metal. I have been deceived more than once. When, 
 for purposes of comparison, I have examined the hilum in 
 cases where it was known that no foreign body was lodged 
 there, I have realized how exact was the mimicry of a pro- 
 jectile by the hard, rounded, but irregular condition of a 
 bronchus. 
 
 Notwithstanding these several points, there is no need 
 to modify the ordinary open procedure which I have de- 
 scribed. Some surgeons have preferred the flap opera- 
 tion, which, as Le Fort has shown, is especially applicable 
 in some operations involving the mediastinum. That 
 more room is thereby gained is indisputable; but more 
 room is never needed, for all requisite manipulations are 
 possible through the ordinary incision. The flap method 
 is certainly a little more formidable; inflicts a greater dam- 
 age on the chest; and implies a more protracted conva- 
 lescence, and perhaps a weaker chest wall in days to come. 
 
 Le Fort himself (Bull, et Mem. Soc. de Chir., 1917, p. 
 1142) obtains adequate room by making an intercostal 
 incision, dividing the costal cartilages above and below, 
 and displacing them upwards and downwards by strong 
 retractors. An approach to the hilum from behind is ad- 
 vised by Petit de la Villeon (Bull et Mem. Soc. de Chir., 
 1918, p. 976), who describes an area bounded on the inner 
 side by the spine, on the outer by the border of the scapula, 
 above by the 5th rib, and below by the 8th rib, as that in 
 which the shadow of the root of the lung falls. If a piece
 
 THE SURGERY OF THE CHEST 239 
 
 of metal is seen in this area, and is gauged to be at a depth 
 of from 6 to 13 cm. from the posterior surface, it lies in the 
 root of the lung. His operation is practised in three 
 stages: 
 
 Stage 1. Performed in a strong red-orange light. The 
 patient lies prone. The omovertebral space is opened, and 
 resection of the necessary ribs (6th, 7th, and 8th) is per- 
 formed; the resection is made as wide as possible to give 
 free access. The pleura is opened. 
 
 Stage 2. Performed under x-ray, with screen examina- 
 tion. A long pair of forceps is passed through the visceral 
 pleura and the lung to the hilum. Guided by the image 
 on the screen, the forceps seizes the foreign body, grasps 
 it, and is held steady. 
 
 Stage 3. In daylight. The forceps is withdrawn with 
 the projectile. Into the wound made by the forceps the 
 surgeon plunges his left index-finger; this he gradually 
 withdraws, packing gauze in long strips into the cavity it 
 occupied. The wound in the parietes is closed. The 
 packing remains for forty-eight hours, being loosened first 
 by hydrogen peroxide. It is thought that the free pneu- 
 mothorax aids in haemostasis. Sixteen cases are recorded, 
 with 16 recoveries. In none was there any haemorrhage. 
 
 The method of Petit de la Villeon has obtained a degree 
 of success denied to all other procedures. It requires a 
 special installation of light and x-ray, and an apprentice- 
 ship on the part of the operator in the extraction of foreign 
 bodies under screen examination. Its success depends 
 upon details; but its success is no detail. Probably a 
 combination of the anterior operation with a screen ex- 
 amination at the time of searching within the hilum for the 
 projectile would be an improvement upon the original 
 method. And no small part of the success of the opera-
 
 240 ESSAYS ON SURGICAL SUBJECTS 
 
 tions performed by Petit de la Villeon depend upon his 
 fully-trained capacity for details and for dainty operations 
 of this type. 
 
 5. Operations Upon the Mediastinum: 
 
 Access to the mediastinum may be obtained either by 
 the operations already described, in which one rib alone 
 is elevated or removed, or by methods specially devised 
 to give ample access. Of these special methods the fol- 
 lowing may be briefly described. 
 
 1. The costal flap with external hinge of Delorme, modi- 
 fied by Le Fort (whose description I give) : 
 
 This flap is cut widely and regularly by dividing the 
 costal cartilages and the intercostal spaces at equal dis- 
 tance from the bordering ribs (so as to permit the repair 
 of the wall) ; it is then raised, guarded against fracture of 
 the ribs either by simple elevation if the flap can be ex- 
 tended very far outward, as is the case with the lower ribs, 
 or by causing a greenstick fracture by strong but cautious 
 pressure, as can be done in the majority of patients up to 
 and even above thirty years of age. 
 
 This procedure provides the most light, permitting 
 complete exploration of the entire thoracic cavity, from 
 the clavicles as far as the diaphragm, and from the ster- 
 num to the vertebral column and the ribs behind. It facil- 
 itates all manipulations, the introduction of both hands 
 and instruments into the interior of the thorax, and the 
 direct inspection of the entire cavity. Very recently I 
 succeeded without difficulty in obtaining hsemostasis of the 
 wounded azygos major vein behind the diaphragm, by 
 means of an anterior flap. 
 
 2. Le Fort's method of intercostal incision associated with 
 division of the supra- or subjacent costal cartilages: 
 
 As in the case of the flap with an external hinge of
 
 THE SURGERY OF THE CHEST 241 
 
 Delorme, the procedure causes no mutilation of the 
 thorax. The repair of the wall is easier and can be made 
 even more accurately than after the Delorme flap, and the 
 operation is perhaps even more free from danger. The 
 procedure permits the breach in the chest wall to be made 
 more or less extensive according to the necessities of the 
 case. A simple incision of one intercostal space permits 
 separating the ribs by about 6 cm. ; division of the cartilage 
 above or below permits of a separation of 8 cm. ; division 
 of both cartilages together gives an opening of about 12 
 cm., and the supplementary division of another cartilage 
 enables one to enlarge the separation to 19 cm. It is very 
 advantageous always to make the incision in an intercostal 
 space sh'ghtly below the level of the foreign body which is 
 to be extracted. This way of proceeding has a twofold 
 advantage: on the one hand, the avenue of access supplied 
 by the incision of an intercostal cartilage is so much the 
 larger the lower the intercostal space; on the other hand, 
 the intercostal incision combined with incision of the 
 costal cartilages above can be very easily transformed into 
 a costal flap by simple section of a higher intercostal space. 
 3. The sternockidocostal flap method, suggested by Duval: 
 This operation provides free access to the cervico- 
 mediastinal "cross-roads," to the arch of the aorta, the 
 origin of the carotids, the brachiocephalic trunks and the 
 subclavian veins, the internal portion of the apex of the 
 lung, and the entire half of the superior mediastinum, 
 without sacrificing the clavicles, without opening the 
 sternocostoclavicular articulations, without damaging any 
 organ, vessel, nerve, or important muscle. It consists in 
 turning upward and outward a flap which comprises the 
 clavicle, the first rib, and the upper outer segment of the 
 sternal manubrium where these bones are inserted. 
 
 16
 
 242 ESSAYS ON SURGICAL SUBJECTS 
 
 4. Median division of the sternum, pericardium, and 
 diaphragm Duval's method: 
 
 This provides free access to the heart, and is recom- 
 mended for certain operations upon the right heart. 
 Sometimes it may be desirable to add to the flap with an 
 external hinge a small sternal flap with an internal hinge, 
 etc. 
 
 The detail of these procedures does not really make 
 much difference. The indispensable requirements are to 
 provide all the necessary light for the operative interven- 
 tion by means of a large gap, which can be further en- 
 larged should an unexpected necessity arise; and to avoid 
 all permanent mutilations, so as to permit an essential 
 repair of the thoracic wall after the completion of the 
 operation. 
 
 The relative advantages and difficulties of these several 
 methods have been briefly indicated in the description of 
 each. For the removal of small projectiles lying free in 
 the lung which has no serious adhesions to the chest wall, 
 the method of Petit de la Villeon is the easiest, safest, and 
 least disturbing. 
 
 For all foreign bodies in the hilum, or in the medias- 
 tinum, or in the heart, an open operation is necessary. 
 For many of these the operation in which one rib is ele- 
 vated and resected is generally adequate. If it is neces- 
 sary to have more ample space and a better view, the 
 operations of Delorme, Le Fort, or Duval will be per- 
 formed. The operation of Petit de la Villeon, in which the 
 hilum is approached from behind, appears to be attended 
 with great success, but, so far as I can learn, has been prac- 
 tised only by him.
 
 THE SURGERY OF THE CHEST 24? 
 
 D. AFTER-HISTORY AND RESULTS OF OPERATION 
 
 To my regret it has not been possible to make such 
 comparison as I consider necessary between the conditions 
 of the patients before operation and afterwards, especially 
 months afterwards. The men upon whom I have oper- 
 ated are scattered about the country from Aberdeen to 
 Cornwall; most of them are back at work, and it has been 
 quite impracticable to get them to come for a medical and 
 radiological examination. In most of the cases I have 
 therefore to rely upon the patients' testimony. It is not 
 certain that this is always as satisfactory as it might be; 
 for more than half the men make some bitter reference to 
 the dealings of the Pensions Ministry with them ; of reduc- 
 tions which they consider untimely, or unfair, in the 
 weekly pension. Some of the letters seem to express a 
 fear that a too favourable report may result in a pension, 
 already meagre, being further reduced ; but the evidence is 
 the best accessible. I have accordingly written to all 
 patients, and their answers are given in the appended case 
 reports. 
 
 As a class, these reports contrast in a very striking 
 manner with those which I received almost at the same 
 tune from some of the patients upon whom, in recent 
 years, I performed partial gastrectomy for gastric ulcer or 
 gastric cancer. In the pleural cases it is comparatively 
 rare to find the patient saying that he is entirely free from 
 trouble. There is not infrequent reference to breathless- 
 ness on exertion, or to a h'ttle pain. There is rarely any 
 mention of cough, and none of haemoptysis. These two con- 
 ditions are certainly relieved by the removal of the foreign 
 body; but the functional troubles persist in some de- 
 gree.
 
 244 ESSAYS ON SURGICAL SUBJECTS 
 
 Does the persistence of some of these symptoms depend 
 upon the operation performed? Is it, for example, a wise 
 procedure to separate all adhesions binding the lung to the 
 chest wall? In the presence of numerous and strong ad- 
 hesions there does not appear to be necessarily any pain, 
 nor any shortness of breath except on exertion. It is true 
 that the lung then acts imperfectly, that it shows evidence 
 of collapse in greater or less degree. My hope was that 
 the free and open operation which I have customarily 
 performed, together with the fearless separation of all ad- 
 hesions, might do something to restore the lung to its full 
 free function. And in some cases this hope has certainly 
 been fulfilled. It is a very striking phenomenon to witness 
 the gradual expansion of the lung when thick adhesions are 
 separated, or tough heavy membranes stripped from its 
 surface. The lung grows bigger and fuller under one's 
 eyes, and it is evident that there has been compression as 
 well as a willing collapse on the part of the lung. But in 
 some cases the results that have followed have been below 
 my expectations. As some of the late reports show, there 
 is evidence still of restricted capacity for breathing, of 
 effort dyspnoea, and of some pain. And the physical ex- 
 amination shows also that in some cases a degree of 
 collapse is still present. The most certain test of a lung's 
 free activity is perhaps afforded by an inspection of the 
 range of movement of the diaphragm watched on the x-ray 
 screen. In several patients there has been witnessed an 
 increasing range, as function was restored. In a few of 
 our patients the mobility of the diaphragm did not visibly 
 increase. 
 
 The condition of the elevated rib is in all cases quite 
 satisfactory. Sound union has occurred; and the chest 
 wall may be said to be as strong and firm as ever.
 
 THE SURGERY OF THE CHEST 245 
 
 SUMMARY 
 
 The following is an epitome of my experience : 49 cases 
 have been treated by operation; 2 cases have died, one 
 from hemorrhage following the removal of a projectile 
 from the root of the lung, and one from sepsis after the 
 removal of an infected foreign body and a piece of clothing. 
 
 The late history has been obtained in 43 cases. The 
 results may be described as Good, Fair, Bad. 
 
 1. Good Results. These patients are, they say, in per- 
 fect health, and are able to do heavy work. Of these 
 there are 24, equal to 55.8 per cent. 
 
 2. Fair Results. Some of these patients are better 
 than before operation, but still have some shortness of 
 breath, or unusual respiratory trouble when having a cold, 
 or in bad weather. Some are a little better since the opera- 
 tion. Of these there are 14, or 32.5 per cent. 
 
 3. Bad Results. Two patients died; 3 are unable to do 
 any work, or have serious respiratory trouble, shortness of 
 breath, cough, etc. 
 
 The position of the foreign body in the 49 cases was as 
 follows: 
 
 Left lung. Right lung. 
 
 In upper lobe 4 4 
 
 In middle lobe 1 
 
 In lower lobe 10 13 
 
 In root 5 2 
 
 19 20 
 
 In and adherent to pericardium 4 
 
 In heart muscle 1 
 
 In diaphragm 1 
 
 In pleural cavity (loose) 1 
 
 In body of vertebra 1 
 
 Not mentioned 1 
 
 ? Present (lung gritty and probably tuberculous) 1 
 
 10
 
 ESSAYS ON SURGICAL SUBJECTS 
 
 All but 5 were operated on by the ordinary anterior 
 method. The 5 operated on by direct attack from behind 
 show 4 with good ultimate results, 1 with fair result. 
 
 Eighteen of the foreign bodies were examined bacteri- 
 ologically; 11 were infected with Staphylococcus aureus, or 
 Streptococcus brevis in equal numbers, or by these organ- 
 isms together with coliform bacilli; 7 were sterile. 
 
 Empyema after operation developed in 5 cases, and in 
 each of these, when the foreign body was examined, it 
 was found to be infected. In 12 cases blood collected 
 after operation in sufficient quantity to require aspira- 
 tion. In all these the adhesions were dense, and were 
 widely separated. These 12 include the 5 reported above, 
 which subsequently developed empyema. Of the 7 which 
 did not suppurate, only once was the foreign body ex- 
 amined, and it was sterile. 
 
 In 10 cases the original injury had been followed by 
 empyema. The only effect this had at the time of re- 
 moving the foreign body was that adhesions were found to 
 be very dense and extensive. Three cases were reported 
 as having had haemothorax at the time of the original in- 
 jury; at the operation for removing the foreign body, ad- 
 hesions were dense; in two of these three cases an exceed- 
 ingly thick blanket-like membrane had to be removed by 
 scissors to allow the expansion of the lung.
 
 "THE MOST GENTLE PROFESSION"' 
 
 Delivered at the Annual Prize Distribution to the Nursing Staff of the Leeds 
 General Infirmary, January 21, 1921. 
 
 THE memory of unpleasing things is very tenacious. 
 A century ago an operation was attended by a variety 
 of circumstances calculated to arouse dismay and keen 
 anxiety in every heart; and to-day the very word "opera- 
 tion" sends a shudder through many of those who learn 
 that it is to be their early destiny. And this dread con- 
 tinues, though you and I know that an operation is an 
 act of gentlest mercy, guided and determined by the 
 utmost skill, inspired and controlled at every stage by 
 compassion for the sufferer. To the word "nurse" a 
 similar obloquy still attaches. Even now the word con- 
 jures up in some minds the picture of a bibulous and 
 crapulous hag, unversed in the simplest rudiments of her 
 art and indifferent and insensible to the needs of others. 
 Her picture has been drawn by many hands; it was 
 coarsely exaggerated, no doubt, even in Dickens' day, 
 but the recollection of it is still fresh in many minds, 
 though you and I know that the nurse of to-day is one 
 of the most gracious and most competent of women, and 
 that the profession of nursing now attracts the best type 
 of womanhood that this country can produce. 
 
 DIFFICULTIES ENCOUNTERED IN PRIVATE NURSING 
 
 But those of you who leave this hospital to go out 
 into the world to nurse must not be surprised if you 
 find that you are not welcomed with that open, eager 
 
 1 Reprinted from "The Hospital," January 29, 1921. 
 247
 
 248 ESSAYS ON SURGICAL SUBJECTS 
 
 enthusiasm to which your training and your experience 
 will fully entitle you. In your hospital life you are 
 the despots, most merciful despots it is true, of all your 
 patients, who conform with no word of denial or con- 
 tumacy to all that is demanded of them or imposed upon 
 them. They accept without question the discipline of 
 the hospital and the beneficent rule of its officers. Of 
 your work in private much will have to be done in the 
 homes of your patients. Happily the day is almost past 
 when an operation of any magnitude has to be performed 
 in the unsuitable surroundings of a private house, with 
 all the makeshifts and dangers inseparable from such 
 work. But the convalescence of surgical cases and the 
 whole course of a grave medical illness will be passed 
 in a private house to whose rules and customs you will 
 be expected to conform, in which, however great your 
 competence and however congenial your society, you are 
 an intruder. You will be compelled, looking only to your 
 patient's welfare, to intervene between him and his 
 friends, often running counter to their wishes and their 
 normal practice as you shelter him from their well-meant 
 but harmful attentions. It will be one of your many 
 testing times, when you will require all the gifts, all 
 the tact, and all the accomplishments that your natural 
 aptitude, or your long training, have conferred upon you. 
 
 LEARN TO USE KNOWLEDGE JUSTLY 
 
 How are you to fit yourself for such tasks, or to 
 become competent to undertake with highest success all 
 the manifold and arduous responsibilities that lie ahead 
 of you? First, you will need knowledge. To gain it in 
 an adequate degree you will require intellectual powers 
 of no mean order and industry above the average. There
 
 " THE MOST GENTLE PROFESSION" 249 
 
 is much to be learnt of anatomy, of physiology, of medi- 
 cine, and of surgery; of the principles which underlie 
 the technical work you will daily practise. You will have 
 to avoid the little knowledge which is dangerous by 
 delving as deeply as you can into those things which 
 apply most nearly to your own tasks. It is better to 
 learn intimately the relevant matters than to have a 
 smattering of many things that it is not within your 
 strict province to know. But knowledge which is within 
 the reach of everyone who truly seeks it will avail you 
 little unless it leads you along the way to wisdom. Wis- 
 dom implies the timely and rightful application of 
 knowledge. Knowledge may even be a pitfall or an 
 encumbrance unless you learn to use it justly. To gain 
 wisdom is of all tasks in life the most difficult, and it 
 is certainly no less arduous in nursing than in many other 
 of life's activities. You will be foiled and rebuffed and 
 disheartened, not once but many times, as you toil 
 earnestly after it, for the application of the truths you 
 have learnt may be so diverse, the reactions so unexpected 
 and perplexing, and the personal aspects of them so 
 capricious, that you may think of wisdom as Fracastorius 
 did of the beating of the heart that it "is so difficult as 
 only to be comprehended by God." 
 
 You will have duties, fewer than they formerly were, 
 which may appear menial or degrading, and they will 
 sometimes need to be carried out upon those who are the 
 mere wreckage of humanity. But drudgery may be a 
 blessed thing, and you may derive consolation from the 
 remembrance of One who thought it no ill task to wash 
 the feet of the humblest of people. And you will perhaps 
 day after day, especially in your early years, be almost 
 dead with fatigue, embittered by the disappointments of
 
 250 ESSAYS ON SURGICAL SUBJECTS 
 
 a case that has gone wrong, or wounded by a rebuke 
 that has escaped from the lips of someone as weary and 
 disheartened as yourself. Yet all the time you must 
 show your best side, for you cannot give real help to 
 others if you seem careworn or dejected. You must learn 
 to bring an air of pleasure to the pursuit of duty. And 
 so by degrees you will learn that it is not only knowl- 
 edge, or even wisdom, but also, and chiefly, character 
 that counts. You will learn to deal faithfully, stubbornly, 
 and with untiring zeal with all your difficulties, and the 
 word "trouble" will vanish from your vocabulary. No 
 patient can ever cause you "trouble" if you remember 
 that what is a daily and perhaps monotonous event to 
 you is the great event and perhaps the sternest trial of a 
 lifetime to him. Your patient's needs are your oppor- 
 tunity. 
 
 THE NOBLEST FUNCTION OF MAN 
 
 You will soon divine the great secret that in many 
 patients who are seriously ill the restraints which adult 
 life impose upon us all, fall away. The qualities of 
 childhood again emerge; there is a trustful dependence 
 upon others; there is great need of sympathy and un- 
 derstanding; there may be a little petulance, a little 
 fretfulness, a querulous demand for many things un- 
 suitable. You may need great patience, infinite gentle- 
 ness, unfailing forbearance, if you are to read your 
 patient aright, and to serve him to the utmost of your 
 capacity. Service is the noblest and happiest function of 
 man. And to render the highest service you must attune 
 yourself spiritually with your patients, so that you may 
 read their hearts, discover their motives, divine their 
 impulses, and lead them at last to realise that you stand 
 loyally behind them, or beside them, to help them, not
 
 "THE MOST GENTLE PROFESSION" 
 
 over against them to thwart them. And at all times you 
 must keep reticence. Many secrets that have perhaps 
 been most jealously guarded will be disclosed to you, and 
 many of the most sacred mysteries will be revealed. You 
 will preserve an inviolable silence. For taciturnity is an 
 ornament, and in silence there is security; if you repent 
 once of your silence you will repent ten times of your 
 speech. You will find help from the 39th Psalm, "I will 
 take heed to my ways that I offend not in my tongue. 
 I will keep my mouth as it were with a bridle." To 
 chatter of those intimate things you learn under the seal 
 of the confessional as you work is a degradation of 
 your calling. Gossip tainted with slander is the last and 
 meanest infirmity of empty minds. 
 
 THE NURSE'S OFFICE 
 
 Such are some of the qualities required by a nurse, 
 and this then is the nurse's office. To be ready in all 
 emergency, quick and competent in action, courteous in 
 speech, considerate in thought; a comfort in hours of 
 sorrow, an inspiration and encouragement in times of 
 gloom ; to give ease to many a weary body and solace to 
 many a troubled heart; to lift with strong and gentle 
 hands a heavy load of anguish from those who falter and 
 stumble in despair. It is to be a beacon of hope, a rock 
 of refuge, and a tower of strength. 
 
 If your attainments are these and your work of this 
 high order, you are members of a profession than which 
 none is gentler or nobler. Your watchwords become 
 "service and self-surrender." You do not seek reward or 
 selfish gain. Your work will be done in a professional 
 spirit; it will be done, not in the most meager way for the 
 utmost gain, but with all the energy and truth that
 
 252 ESSAYS ON SURGICAL SUBJECTS 
 
 you can put into it. The true rewards of honest work 
 are neither to be seen nor handled, they are not measured 
 by a gold standard nor by any material result. They 
 are not acclaimed by the applause of the crowd. They 
 lie within you; in your own knowledge that you have 
 done your best, that you have striven to reach your 
 own standard of your highest powers. You will often, 
 perhaps always, fail to reach your own ideal; but be 
 comforted. Ideals are not for attainment, but for 
 pursuit. 
 
 RECOGNITION OF EFFICIENCY 
 
 If you enter a profession and become adept and 
 worthy members of it you should receive the proper 
 recognition to which your work entitles you. The time 
 is now ripe, in my opinion, for your acceptance by some 
 academic body which shall control the training and direct 
 the teaching of the nursing profession, and in due time 
 confer authority by licence, or diploma, or degree, upon 
 those who have attained the standard of efficiency that 
 is considered adequate. Your work, whether regarded as 
 an intellectual task or as a technical accomplishment 
 demanding the exercise of fine craftsmanship, fully en- 
 titles the nursing profession to make such a demand as 
 this. If such a recognition comes, then will follow a 
 result I have long desired to see. There will be a grading 
 of nurses by qualification as there is a grading of medical 
 men. It is, I think, just as necessary that a sister in 
 charge of a ward, a theatre sister, or a matron in a teach- 
 ing hospital should bear evidence in her qualification of 
 longer study and more careful training as it is in the case 
 of the medical staff of a teaching hospital. Until some 
 system of supervision of the training of all who may call 
 themselves nurses and of the registration and quafrfica-
 
 " THE MOST GENTLE PROFESSION" 253 
 
 tion by diploma or degree is introduced, the nursing pro- 
 fession will not be cleansed from those impurities which 
 still unhappily attach to it. 
 
 THE HONOUR OF THE TRAINING SCHOOL 
 
 In Leeds you are fortunate in your school. The train- 
 ing through which you pass here is as long, as arduous, 
 as strict as it is anywhere in the world. And the honour 
 of your school is of the highest; it has been created, 
 maintained, and increased by the great multitude of your 
 predecessors. Remember that you all carry with you, 
 wherever you go, the honour and good repute of your 
 school. Every one among you can add to that store of 
 honour or detract from it. Leeds will be judged by your 
 work and by your demeanour. And when the time comes 
 for you to lay your work aside the highest praise that 
 can be given to you will be that you have worthily upheld 
 the high traditions of your own school and the dignity 
 of the most gentle profession.
 
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