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BY F. C. SHURTLEFF, M, D., LOS ANGELES, CAL. Mr. President, Ladies and Gentle- unremitting efforts of investigators men: In conformity to a request from along these lines, and of the vast our worthy president, I herewith pre- amount of knowledge gathered from sent you with a synopsis of the prog- them, which has been our heritage ress of surgery in the last one hun- from the past, as “Many of the discov. dred years. The shelves of our libra- eries in modern surgery are but the ries are
groaning today under the rediscoveries of discoveries effaced weight of knowledge imposed upon from the memory of man." The factthem in the various branches of med- ors which have revolutionized the suricine and surgery. It may appear to gery of the past and permitted us to you as presumptuous upon my part to attain the results we do today, are crowd into the fifteen minutes allotted
the employment of general and local me such an extensive subject as we anesthesia and a rigorous following have in hand; if so, I beg your in- of antiseptic and aseptic principles; dulgence. “The stupendous progress the employment of antitoxines for inmade in the art of surgery in the cen- operable cases should not be forgottury about drawing to a close renders ten; the devotion of time to specialit advisable to cut loose from the doc
ties; last, but not least, the various trines of our forefathers in reference ligatures, and a better understanding to the management of certain surgical of their preparation. The discovery affections, as evidenced by the results of the ophthalmoscope foreshadowed attained today through a more thor- by Cummings and invented by Helmough understanding of bacteriology, holtz, in 1851, made a future for eye transmitted from Pasteur and his fol
surgery and placed it upon the emilowers since 1857."
nence of which she is justly proud toThe importance of bacteriology has day; by it the scientific correction of not been overestimated, and it is with errors in refraction are made, and as reverence that we should think of the an instrument for diagnosis it has no
'Read before the Los Angeles County Medical Association at the annual meeting December 2, 1900.
peer. The reintroduction of the speculum vaginae by Recamier in 1801 gave an impetus to gynecologists and awakened them from their lethargic sleep, causing a revival amongst abdominal surgeons, which is unprecedented in surgical history. More light! was the cry of Czermak, and the laryngoscope was born. What greater aid to the genito-urinary surgeon than the perfection of the sound and the invention of the cystoscope? The old-fashioned tourniquet, as devised in 1718 by Petit, had to be abandoned for Esmarch's elastic bandage; hence the honor of perfecting artificial Ischemia is certainly due to Esmarch. What a blessing to suffering humanity have ether, chloroform, nitrous oxide and chloride of ethyl proven themselves, as they lull to sleep and blunt pain during a surgical operation. In ancient times cannabis indica and opium were the ch ef remedies for controlling pain at an operation, or the patient was made to swallow a decoction of mandrake with wine, or an attempt was made to stupify the patient with the fumes of hemlock before submitting to the knife. Cloquet as late as April 8, 1829, is said to have removed without pain a cancer of the breast during a magnetic sleep. From the dawn of the Christian era until 1846, surgeons had endeavored to render surgical operations painless, but it took the 19th century to bring it forth. "Before the introduction of anesthesia, haste in operative work was a great desideratum. Now it cannot be condemned too strongly" (Stephen Smith). Cocaine for local anesthesia cannot be lauded too highly, thanks to doing away with a freezing mixture of salt and ice, and next to the ophthalmoscope has given ophthalmic surgery its present status. Operations upon the nose and throat or genito-urinary tract are rendered painless. Since the introduction of antiseptic surgery the outgrowth
of Listerism, those cavities that were once considered sacred, are now operated upon with almost perfect impunity, and the mortality has been reduced to the minimum; by its employment surgeons have been enabled to invade the cranium and explore the brain, and to open the thoracic or abdominal cavities that would necessarily have caused a fatal issue before its introduction. Previous to the discovery of antiseptics the question was, “How much pus in a given case?" Now, “Is there any?" As my friend, Dr. Geo. Abbott, of Pasadena, put in the opening address at the medical college of this city one year ago, “The question now is, “Not how did you get such a result, but, why did you not get it?" "It is your business to get it." Druitt in 1877 said: "Antisepsis is regarded as still on its trial; ligatures are left hanging from the wound; the extraperitoneal method is recommended in ovariotomy, and we are told to hang a box of Macdougall's powder under the bed-clothes to keep down the stench of a stump." Sir Spencer Wells made the statement “that he believed the time would come when we would be able to find one set of harmless germs that could be introduced into the system and made to devour a set of injurious ones, acting somewhat as vaccination does in smallpox," so it is evident to you all the progress we have made over his time, as evidenced in the treatment of anthrax, tetanus, septicemia, rabies, myedema and certain varieties of cancer. I predict that antiseptic or aseptic surgery makes possible the surgery of the heart itself in the coming century. “Formerly the surgeon was unclean, not only so far as hands and field of operating were concerned, but employed instruments taken from their case without any preparatory cleansing. If he was unfortunate enough to drop an instrument during
the operation, he picked it up from the floor and immediately reapplied it to the wound without cleansing it from dirt. Now the utmost precautions are observed in reference to handcleansing. The donning of sterilized gowns and caps to protect the wound, not only a shaving of the part, but a thorough scrubbing with soap and water followed by antiseptic solutions and then by sterile water, and then the field of operation is surrounded by sterilized towels. Formerly the germ retaining sponge
used. Now pledgets or sterilized patties of gauze are employed. Formerly silk ligatures were carried loose in the vest pocket or operating case, with no special effort to keep them clean; they were regarded as foreign bodies in a wound, and had to suppurate away. Now they are carried in sterilized envelopes or in glass tubes. In reading a report of the old master surgeons that bystanders explored the wound not infrequently (a thing that would be criminal at the present time without previous preparation). I quote Stephen Smith: “No one is now allowed, invited by courtesy, or to obtain an opinion to examine a wound by digital exploration unless they have made due preparation for the act.” What a change for the better has been made in ref. erence to drainage or non-drainage of wounds. “Asepsis has taken the place of antisepsis, not only so far as healing of wounds are concerned and the effect upon the tissues, but it is now antisepsis before operation, asepsis after." The progress of surgery is manifest on every hand, as evidenced in the partial amputation of the foot instead of the whole, as seen in Lisfranc's operation for removal of the metatarsus of Pirogoff, Chopart and Symes for disarticulation of the tarsal bones. Bloodless amputation at both hip and shoulder joint; resection of bones, preservation of the periosteum
and consequent development of new bone, the ligature of arteries within the trunk, operations for cleft palate and club foot, intubation instead of tracheotomy, removal of cataract so that, verily, the blind do see; extirpation of the uterus, both by the abdominal or vaginal routes; ovariotomy and partial resections of tubes or ovaries, resection of lower part of the rectum; repair of cervix and perineum; the treatment of varicose veins, ununited fractures, recto-vaginal and vesico-vaginal fistulae, the introduction of immovable apparatus for fractures; the improved method of treating ulcers and abscesses; operations for cure of aneurisms by ligature of carotid, subclavian, axillary, humeral, external and internal iliacs. The diagnosis of tumors and their treatment, whether fatty, vascular or malignant. Plastic operations upon the nose and lips; the conservative treatment of gunshot wounds; surgery of the liver and spleen; excision of diseased joints in cases where the whole limb would have been removed formerly; resection of the upper and lower jaw; removal of tongue, appendix, stomach, kidney, prostatic gland, and the late Botini operation. Improvement for the radical cure of hernia, anastomosis between the greater omentum and parietal peritoneum for cure of ascites due to cirrhosis of the liver; crushing of stone in the bladder and catheterization of the ureters; supplantation of the older operation of implanting the ureter into the rectum by vesico-rectal anastomosis; resection of cervical sympathetic ganglion as a curative measure in the treatment of epilepsy, glaucoma, and exophthalmic goiter. Intestinal anastomosis by the Murphy button, Abbey's rings and Senn's plates; by cerebral localization, tumors and abscesses are now operated upon with great precision, and the success of brain surgery is assured in the future. In closing I would be remiss in my duty did I not mention the crowning event that has characterized the progress of surgery in the century so near its end-that of the discovery of the X-ray and its application to surgery. By it the diagnosis of fractures or dislocations are made certain; the detection of foreign bodies, the pathological changes in bone tissue are depicted; calculi are made visible, particularly in bladder or kidneys. “The mantles of Cooper,
Bell, McDowell, Lister, Pasteur, Billroth, Koch, Bigelow, Warren, Hamilton, Agnew, Gross, Goodell, Skene, Tait and many others, too numerous to mention, have fallen on worthy shoulders, and the coming generation will accord to many now living places beside the pioneers who have rested from their labors.”-Park. Thus we can say truthfully of surgery, as of every advancing art, It has no goal-its law is progress.
45242 South Broadway.
THE AMERICAN CIGARET.
BY WILLIAM S. FOWLER, M.D., VENTURA, CAL.
In the January number of your journal Dr. Seymour unqualifiedly condemns the American cigaret, and because the article from his pen is representative of a large class of writings of similar character, I feel compelled to pick a few holes in it, admitting, as a preliminary, that the article under consideration is not a sample of the author's best work, having little of his trenchant, logical style. Perhaps it was written under the influence of a spirit of indignation called forth by some unusually flagrant case of tobacco intemperance.
Cigarets made by American factories have been the subject of exhaustive analyses by physicians and scientific experts, men anxious to find the presence of “drug addition," and the universal testimony of these investigations has been to show that there was no addition of harmful drug substances to the tobacco used in the manufacture of cigarets. Prof. Ogden Doremus says he failed to find anything but tobacco in any brand of American cigarets. It is not surprising that a confirmed smoker should find satisfaction in some brands and not in others, and the fact
of his having been a cigar user before makes him little, if any, more competent to judge of the presence of adulterants, because the same character of tobacco is not used in making cigarets that is used in cigars.
Those familiar with the stock arguments against cigarets will recall that at first the deleterious effects were attributed to the paper wrapper alone and when the fallacy of this contention was shown, the supposed use of cigar stumps gathered in large cities a means to disgust cigaret users with by child scavengers from gutters and garbage boxes was brought forward as their means of enjoying tobacco (why refuse tobacco was more harmful when gathered by children does not appear); but this argument was as ruthlessly swept away as the story of the death that lurked in the paper covering, and there remains at the present time no satisfactory evidence that the same quantity of similar grades of tobacco is more injurious when smoked in the form of a cigaret than it would be if consumed in a pipe or cigar in the same manner.
It is easy to jump at the conclusion that because a smoker prefers one brand of cigarets and finds no satisfaction in others that the particular brand so satisfying has been made more effective by the addition of some drug, but it is not evidence and the possibilities of other reasons should be evident to the critical judgment of a physician.
Factory-made American cigarets are made by automatic machinery that cuts, gums and rolls the paper over a measured quantity of tobacco, sticks the gummed edge and packs the finished cigarets into boxes which are labeled before leaving the machine; in other words, tobacco, paper boxes and gum are fed into a machine which delivers packed cigarets, so there is no possibility of the little paper sticks having been licked by a tuberculous or syphilitic factory hand, being in this respect less liable to contamination than the cigars which seem for the present to be escaping the onslaughts of anti-tobacco users.
Many brands of foreign-made cig
arets are rolled loosely and not gummed, necessitating re-rolling before consumption, and smokers who use these or who roll their own cigarets soon learn that licking the paper is unnecessary, the little pipe burning quite as satisfactorily without.
It is within the bounds of the possible that what is said to be a popular clamor against cigaret-smoking has been largely promoted by the cigar and chewing tobacco manufacturers, and while no attempt will be made to show any beneficial effects from the use of tobacco in any form by adults, it would seem that the cigaret is the most decent, clean and civilized method of using the weed. The use of tobacco is unquestionably deleterious to the immature, even working in a tobacco factory shows its detrimental effects on growing children, but used in moderation by mature, adult individuals, it gives a philosophic repose to body and mind with less evil than can be derived from other means.
WHERE DO WE STAND.
BY W. W. APPLE, M.D., LOS ANGELES, CAL.
In beginning this paper I desire to preface it with the statement that it is due to the painful recollection or part guilt that I am led to write upon this subject at this time.
The old adage, “A burned child is afraid of the fire," is no less true when applied to the general practitioner of medicine if he has been standing on slippery ground. I say general practitioner, for those whose business has been more closely confined to surgery and other special lines have been more out of the range of the evil influences which I will speak
of later on, than us poor, unfortunate general practitioners.
I hope not to offend anyone, let him be dispenser of drugs, prescriber of remedies or manufacturer, but by way of beginning will ask: Have you ever thought, when attending a patient, just how much of the management and treatment of that patient was yours? Have you ever thought who was suggesting the remedies to use, the size of the dose, the time and manner of giving, the physiological actions and the therapeutic applications, etc.? Was it you that decided upon every par
*Read before the Academy of Medicine of Los Angeles, Dec. 14, 1900.