BUFFALO MEDICAL JOURNAL.

VOL. LXIV.

JUNE, 1909.

No. II

I

ORIGINAL COMMUNICATIONS.

The Next Twenty-five Years in Surgery.1

BY ROSWELL PARK, M. D., LL. D,

Professor of Surgery in the Medical Department of the University of Buffalo.

AM not unmindful of the consideration and compliment which you have shown in thus featuring me upon this evening's program. It seems as if I never can repay my friends and colleagues who have done so much to make memorable in my life this anniversary of the twenty-fifth year of my teaching in the Buffalo Medical School.

I have been asked to give a glance into the future and to forecast what the next twenty-five years may accomplish in the domain of surgery. To illustrate the impossibility of doing this, I can only mention some of the accomplishments of the past twenty-five years that have so far exceeded our expectations as to show the futility of any such effort; nevertheless, by instituting comparisons between then and now, it may be worth while. at least to make the attempt, although I shall not have the pleasure of saying at the end of the next quarter of a century,-"I told you so."

Twenty-five years ago we used to think that we had about reached the limit of what the surgeon could accomplish, yet such have been the advances made in our art and science that one may epigrammatically yet truthfully say that the impossible or unjustifiable of yesterday has become the commonplace or even the discarded practice of today. I have not infrequently made this comparison, that among all the applied sciences none have made such rapid strides as has surgery, with the possible exception of electricity. Thus today practically no organ of the body has remained unattacked, and it would veritably seem as though, topographically at least. we had reached territorial limits. But

1. Being the substance of an address before the Alumni Association of the Buffalo General Hospital, at a meeting commemorating the author's completion of his twentyfifth year in the chair of surgery.

here we must make a distinction between territorial limits and limitations, inasmuch as while we have brought all the organs into actual touch with the knife, we have not yet learned just how much we can safely do with them. First of all, and with the greatest probability, it may be said that what the surgeon may accomplish will depend in large measure upon the discoveries made during the same period in the physical sciences, and the extent to which he can avail himself thereof. For example, twenty-five years ago who ever dreamed of the possibilities afforded by the cathode rays or by radium. Who could have foreseen the realisation of the old philosopher's dream,-namely, the transmutation of metals; and yet, it is now known that in the presence of radium, copper changes to lithium, and then to potassium and sodium, while the emanation from radium becomes itself neon and argon (Ramsey). These may not have any bearing upon surgery, and yet, I would not like to deny the possibility of a metal suture made, say, of copper, which under the influence of radium applied externally might undergo such changes as to lead eventually to its disappearance, if this were considered worth while.

The new discoveries in physiology and biology have also the widest importance to the surgeon, and are not confined alone to conditions involving the alimentary canal.

When we know more about the actual causes of death we may be better able to avoid them. I have on another occasion coined the expression, "thanatology," which I believe to be a legitimate term that might well be made to cover a systematic study of those causes which bring about actual cessation of life, and that would be a far different study from pathological anatomy though necessarily connected with it. The surgeon then will profit by the erection of thanatology into a distinct science. When, for instance, a heart removed from the body can be made to beat more than forty hours after the death of the individual, then we have a right o raise anew the question: What really constitutes death? We have much to gain from discoveries concerning the blood and sera, the nature and causes of hemolysis, and of the various toxins and substances which produce it. This problem of hemolysis is indeed one of universal interest, but its practical bearing perhaps concerns the surgeon more than anyone else, and for quite obvious reasons, because the importance of supposedly simple transfusion of blood becomes now very great; in fact, every gain toward a more intimate knowledge of our body chemistry can but redound to the benefit of theoretical and applied surgery. Perhaps in no particular direction have we reason to hope for more than in the study of cancer, which still remains second upon the list of the ordinary causes of mortality. In this direction, if I read cor

rectly the signs of the times, we may expect a general recognition of its parasitic character and of its infectiousness, and in proportion as these facts gain in general appreciation we shall have a more well-ordered prophylaxis, as well as much improve cannons of treatment. What we need most of all is such improvement in our powers of diagnosis as to permit an early recognition of deep-seated cancerous lesions at a time when there is still some hope for treatment, be it operative or otherwise. While I dislike to be constantly repeating my own words, this meeting furnishes another possible opportunity to make better known this most important fact, which shall serve but as an incentive to further study and as an excuse for past failure; I refer you to the fact that cancer by itself has absolutely no symptomatology of its own. Signs it has, and when the lesion is superficial these are usually unmistakable. When, however, reliable signs are discovered in a deep-seated lesion it is at a time when hope must be abandoned. Think it over and you will appreciate the fact not yet generally realised that cancer by itself produces no symptom, and often no collection of symptoms, by which alone it may be distinguished; i. e., its symptoms are common to more than one disorder so that there is no reliable guide save the signs above mentioned, and even these too often vague. But with studies and researches such as those already published, it is not expecting too much to hope that the next quarter of a century may afford us some test of an accuracy far beyond any at present in use, by which this most infernal of all diseases may at last be mastered.

And this leads me to speak of improvements in general diagnosis which will be of common benefit to all professional mankind. No one can foresee what these may be, but you may at least rely upon it that the surgeon will be quick to avail himself of any means by which he may improve his knowledge or his skill. Thus we may profit much by a clearer realisation of that unknown relation which exists between the ductless glands and, for instance, the sexual glands, and their relations to sexuality as well as sex problems, and I beg you to notice the distinction I make between these two. In addition to these we shall realise better their relations to such nutritional defects and disorders as imbecility. gigantism, dwarfism and cretinism, rickets and osteomalacia, especially that occurring during the later months of pregnancy. The relation of all of the so-called internal secretions to these and kindred conditions are of the greatest import to the surgeon, since upon his knowledge of what may be accomplished, for instance, by opo-therapy, will depend his selection of or abstention from operative intervention.

Operative Surgery.-Twenty-five years ago we used to think that in this direction the limit had been about reached, and com

parison of a standard textbook of 1880, with that most recently published will show, however, how much further we have gone than we then expected to go. Considering the fact that no organ of the body is now exempt from attack, it would seem as though progress in the future must be rather in the direction of improvenients in technic than in extension of surgical territory.

In the brain, for instance, I look especially for improvement in our treatment of hydrocephalus and of lesions of the hypophysis. In the nervous system there will doubtless be introduced better methods of attacking the so-called neuroses and painful affections of neural origin, i. e., neuralgias. In nerve transplantation and nerve grafting we have not much more to expect than improvements in technical methods, while operation for tumors and compressive lesions of the spinal cord are even now as successful as diagnostic advances permit. It is a question whether success will ever crown operations for repair of a severed cord. Should our successors succeed in this, it would certainly seem as though the very acme of surgical endeavor had been attained.

Regarding the heart, and remembering that it has been many times intentionally punctured by the surgeon, as well as exposed and sutured for repairs of injuries, it would seem as if there were but little left for us to improve upon. It may be that Brunton's suggestion will find favor and that some division of stenotic heart valves will be made practicable, yet concerning these I confess my own skepticism. Possibly something may be done in the matter of so-called heart-block, but not if the anti-vivisectionists have their way, since this would be a matter to be laboriously worked out in the surgical laboratory.

The surgery of the blood vessels will in the future include much freer use of sutures and performance of anastomoses. Doubtless, reversals of circulation will come into play, since Carrel has already shown how perfectly they may be accomplished in animals. I have permitted my mind to perhaps wander a little and to wonder whether it would ever be practicable to connect up the carotid and the subclavian vessels, or possibly the axillary by dividing the carotid as high as possible and then carrying its end over to the subclavian in order to shunt the blood current around some intervening lesion; or whether the saphenous vein and the femoral artery might be in some way interchanged for some similar purpose.

This leads to the consideration of still more radical and, at present, more startling possibilities with regard to the transplantation of tissues and organs from animals to man, or even from man to man. Carrel and his co-workers have recently introduced such innovations in this direction that it is hard to

predict a limit to their usefulness. Thus as showing what may be done, let me remind you of the dog into whose neck he transplanted the heart of another dog, connecting the aorta with the carotid, and the vena cava with the jugular, thus demonstrating the astonishing anomaly of an animal with two hearts beating at different rates; it would be hard to imagine anything of its kind more radical than this. But quite within the limit of human possibilities is the transplantation of a thyroid and perhaps of a kidney.

In animals, also Carrel has demonstrated the feasibility of transplantation of an entire limb, vessel being united to vessel, nerve to nerve, with equally careful suture of all of other tissues, and a resulting remarkable function of the new limb. He has suggested that in the human being it would possibly be practicable to apply this new method in the case of a forearm or even an arm. If so, it would far exceed, as a radical procedure, the cineplastic amputation of Vanghetti, who has recently left the tendons hanging out from the stump resulting from an arm amputation, and has later attached them to an artificial hand and forearm in such a way as to secure much more perfect control of the mechanical fingers and hand. (Illustrated on page 1048 of my "Modern Surgery.") While I have seen some of Carrel's work, and believe in it, I only know of this last procedure from the descriptions in the Italian journals. But no matter what the outcome of Carrel's work, he has already startled the surgical world with what he has shown to be practicable and of great value. It would be the greatest pity were such work as his to be estopped by any fanatic anti-vivisectionist.

We have yet very much to learn and appropriate to ourselves concerning the ductless glands, the hypophysis, the thymus, thyroid, tonsils and adrenals, and we might almost include the bone marrow in this list; their relations to obscure and chronic conditions, which eventually come under the surgeon's consideration, make every advance in our knowledge concerning them of importance to ourselves. Only recently have we learned to what extent their imperfect function may disable the later body welfare. The question of removal of ovaries, for instance, or of the need for transplanting them, is directly connected with these various organs, and such obscure conditions as the status lymphaticus, with all its possibilities of danger, with or without cperation, are inseparably connected therewith. Various internal conditions hinder us largely in some of the work which we might otherwise carry, out-namely, their inaccessibility, and the internal arrangement of their blood vessels which make even satisfactory readjustment next to impossible.

Regarding the improved surgery of the lungs there is yet a