12. SURGERY AND ANESTHESIOLOGY

On a December day in 1809, a farmer waited anxiously while a young doctor, Ephraim McDowell, examined his wife. Mrs. Jane Todd Crawford most certainly appeared to be pregnant, but she was long past her time and still there was no sign of delivery.

The doctor had ridden 60 miles, in midwinter, from remote Danville, Kentucky to help. It was indeed fortunate that there was such a doctor to be had, Farmer Crawford thought. And why the young doctor, who had studied under a famous doctor in Edinburgh, would choose to practice in this pioneer country was difficult to understand. But he had so chosen. And he was here.

The doctor came from the bedroom, his expression reflect­ing his thoughts. Mrs. Crawford was not pregnant, he ex­plained. She had, he believed, a tumor. "It must be removed at once," he decided.

The farmer looked helplessly at the doctor. "Here?"

The doctor shook his head. "Danville," he said. So danger­ous and unprecedented was the operation that he would attempt it nowhere but in his own office.

"But how can we get her there?" Crawford asked.

"She can ride, can't she?"

The farmer nodded.

"Then she'll ride to Danville."

Mrs. Crawford made the 60-mile winter trip on horseback, resting the protuberance of the tumor on the pommel of the saddle.

Subsequent accounts of the episode state that a committee of local doctors and prominent citizens tried to prevent the impending surgery. The doctor and his patient had made up their minds, however.

Dr. McDowell called upon his nephew, Dr. James Mc­Dowell, to assist.

"The day having arrived," Dr. McDowell said later, "and the patient being on the table, I marked with a pen the course of the incision to be made, desiring him (his nephew) to make the external opening, which, in part, he did; I then took the knife, and completed the operation. . ."

Without the aid of an anesthetic or antiseptics, he pro­ceeded with the surgery, defying the common belief of the time that it was fatal to open any cavity of the body, espe­cially the abdominal cavity.

Mrs. Crawford ground her teeth in pain and frequently recited psalms. The doctor worked as quickly as he could with the first ovariotomy to be performed in the United States. On the table, the farmer's wife bore her pain. "The Lord is my shepherd. . ."

After a long ordeal the surgery was finished. A 221/i-pound tumor had been removed from the 45-year-old woman. Dr. McDowell shut his eyes and sighed in relief.

Five days later Mrs. Crawford made her own bed. On the twenty-fifth day after the operation, she returned to her log cabin home and lived for another 33 years.

This was an example of early surgery in America, when folk medicine still was of great importance, and medicine still was groping for the future it was to find in another 150 years.

Men had been practicing surgery for thousands of years before McDowell operated on Mrs. Crawford. Evidences show that almost all the ancients practiced surgery of a sort. Egyptian engravings, made 2500 years before Christ, depict surgical operations.

Ancient Peruvians were skilled in opening veins for blood­letting, setting fractures, treating wounds, and especially in trepanation—which encompasses removing a circular disk or button of bone, chiefly from the skull. Surgeons from a good many other peoples and eras were accomplished in this par­ticular operation. Evidence even indicates that they were performed—probably to allow the escape of a demon causing headache—10,000 years ago in Neolithic times. Ancient Hindus apparently excelled in surgery and used more than a hundred surgical instruments. The early American Indians developed a measure of skill in surgery in the treatment of wounds and fractures.

The North American Indians also developed an effective method for treating snake bites, which involved incision or even excision of the puncture area and the application of suction. Some southwest tribes went beyond treatment and developed immunization, according to some accounts. Indians who participated in the Snake Dance, first submitted to the bite of young snakes with weak virus, gradually submitting to older and older snakes until they could allow themselves to be bitten by full-grown rattlesnakes without suffering ill effects. In Biblical writings circumcision is the only operation mentioned, other than Adam's rib excision. Old China and Japan had no real system of surgery.

The ancient Babylonians obviously practiced surgery. The Code of Hammurabi, composed in 1950 B.C. fixes surgical fees, and penalties to surgeons:

If a physician operate on a man (i.e. gentleman) for a severe wound with a bronze lancet and cause the man's death; or open an abscess (in the eye) of a man with a bronze lancet and destroy the man's eye, they shall cut off his fingers.

If a physician operate on a slave of a freeman with a bronze lancet and cause his death, he shall restore a slave of equal value.

If a physician set a broken bone for a man or cure his diseased bowels, the patient shall give five shekels of silver to the physician.

If he be a freeman, he shall give three shekels of silver.

Of the old civilizations, the Greeks shone brightly in the field of surgery. Hippocrates was a good surgeon. He set frac­tures, drained pus, reduced dislocations, and trephined the skull.

Early Roman surgical instruments found at Pompeii include a scalpel, forceps, tenaculum, forceps with serrated blades, and shears.

During the Middle Ages surgery fared rather poorly and, under the influence of the church, it was relegated, in Europe, to barbers, bathhouse keepers, and almost anyone who cared to try an operation. Considered below the dignity of physi­cians, surgery fell to the lot of "barber-surgeons."

Eventually it rose above its dubious status. During the 17th century there were improved surgical instruments, but disappointing achievements.

In the 18th century, John Hunter was an outstanding English surgeon and modern surgery is reputed to have been founded by him.

It has been said frequently that there are only two periods in the history of surgery—before Lister and after Lister, the famous English surgeon (Joseph Lister, 1827-1912) who introduced his antiseptic system into surgery in March, 1865.

Virtually every community of historical significance has stories of pioneer surgeons performing operations on kitchen tables, by the light of candles, lanterns, or kerosene lamps.

Frequently no anesthetic was available, as in the case of a two-and-a-half-year-old Midwest boy upon whom Dr. H. A. Russell performed an operation for an inguinal hernia in 1832. The case history simply states that the child was given "a suitable dose of opium and a quantity of whisky, and tied to the table."

From these early days of surgery to the modern surgery that takes place across the country every day is a long leap.

Even the surgery of today is far advanced over the surgery and surgical techniques within the memory of many persons.

A grandfather visits his granddaughter of twenty who has had an appendectomy the day before. He stares in amaze­ment when he finds her sitting up.

"Why aren't you in bed, quiet?" he demands.

"They told me to get up, Grandfather."

"But they kept me in bed a couple of weeks, as I recall. At least a week. Won't you hurt yourself sitting up?"

"I guess not. I even walked a little today!"

Upstairs, in Surgery of the same hospital, during an emer­gency operation, a man-made, artificial heart takes over a man's heart functions while surgeons work on the patient.

Before viewing surgery as it is, today, we might well take a quick look at what has been done during the last 20 to 30 years to take most of the great dangers out of surgery by doing something about complications that sometimes arise.

Postoperative Shock once caused more deaths following surgery than anything else. Today shock is infrequent. Proper preparation of the patient for surgery, improved care of the patient during surgery, and the medication used after surgery are very effective in preventing shock. Blood transfusions are of immense value in forestalling shock, as well as plasma and intravenous fluids.

Embolisms no longer are the menace they once were. An embolism is the sudden blocking of an artery or vein, usually by a clot of blood. After surgery it once was not uncommon for a clot of blood to break off from a lower limb and travel to the lung. Now surgeons get their patients out of bed and walking on the first or second postoperative day to stimulate circulation and prevent blood stagnation that might result in a blood clot. Even if a blood clot forms (a thrombus), or even should an embolus develop, injections of heparin may prevent the process from spreading.

Pneumonia, probably the most feared of postsurgical com­plications 25 years ago, now has been all but eradicated by sulfa drugs and antibiotics.

Wound Infections have dwindled to almost negligible pro­portions, and thousands of operations now are performed without a single patient dying as a result of wound infection. Improved surgical techniques and the use of antibiotics are responsible for this improvement.

Postoperative Hemorrhage has become very rare with to­day's improved surgery, suture materials, and eradication of most wound infections.

The old surgeries, some not a great deal better than the inadequate doctor's office, generally have passed into history.

Certainly, any surgery in a modern hospital is almost an age away from the legendary farm kitchen, the kitchen table, and the patient strapped upon it while hot water boiled on the stove to sterilize instruments, and preparations were made to give the patient ether.

Let's take the case of Mrs. Claudia Edwards, 42, who is about to undergo a hysterectomy in a community hospital recently built with the aid of federal funds.

Almost indifferently she watches the activity in the hallway as she waits to be wheeled into the surgery. She is on a hos­pital cart, well covered, and she has been sedated.

Beyond the wide door the surgery is ready. Mrs. Edwards will glimpse the equipment briefly as they take her in, and perhaps she will be vaguely startled by the strange and medi­cal-appearing gadgets. Most of it is far outside her orbit of familiarity. Some of it might even puzzle doctors of thirty or forty years ago.

The center of the stage, of course, is the complex operating table with its lever and wheels and great versatility. On it the patient can be raised, lowered, and tilted in any direction. Patients are securely strapped on it to prevent any slipping or sliding.

Over the table is an expensive and complicated light that is more apparatus than fixture. It is carefully engineered and designed to throw a strong, penetrating, shadowless light over the entire field of operation. Occasionally, other stand lights may be wheeled into place if they are needed.

The equipment near the head of the operating table, on a movable stand, with tubes and tanks of oxygen and various gases is the anesthetic machine.

An instrument table to one side of the room holds all the instruments the surgeon may need. There may be dozens or even hundreds of the instruments ready.

One or two suction machines are on hand to suck mucus from an anesthetized throat, or to remove fluids from the wound.

In addition to the main instrument table there are instru­ment stands, called Mayo stands, to hold the many instru­ments to be used in the operation.

Other equipment includes solution basins; a preparation table that holds soap, alcohol, ether, antiseptics, and gauze pads; waste bucket; intravenous solution and stand; and a clock.

Now Mrs. Edwards is wheeled into the operating room. Already a great deal has been done in preparation for her. Surgery is not a one- or two-man affair in normal hospital procedure. Many hospitals use full surgical teams. Those whom the patient may see will wear uniforms, caps, and masks to keep the spread of bacteria to a minimum.

Few scientific teams are better co-ordinated and more effi­cient than a well-trained surgical team. Usually it is composed of a surgeon; one or two assistant surgeons—depending upon the operation to be performed; the anesthetist who probably will be a doctor who specializes in anesthesiology; a chief operating room nurse; a surgical supply nurse; the scrub or suture nurse who assists at the actual surgery procedure— passing instruments, sutures, sponges and other necessities to the surgeon as needed; a circulating or chase nurse who is ready to keep the surgeon and scrub nurse supplied with the things that are needed, handling all sterile material with a sterile instrument; and frequently an orderly is present to help lift a patient on or off the table and keep the operating room clean.

As the surgical team prepared to follow through with the surgery for Mrs. Edwards, her husband, Ben Edwards—a pleasant, popular car salesman—waited downstairs in a wait­ing room on the floor where his wife would be brought to her room.

Nervously he tossed a magazine aside, got up from an easy chair, walked to a window and stared out into the street. He remembered Dr. Freund's explanation to them the previous week when he had talked to the husband and wife.

"I'm certain it's a fibroid tumor of the uterus. So far there has been no bleeding, but in my opinion it is required surgery within a few weeks, or months, at the most. It's not urgent, yet—but if there is bleeding, it will be. That means within twenty-four to forty-eight hours."

"Then it isn't an emergency?"

"No. Usually we classify operations into five categories. Emergency operations are for conditions that demand imme­diate attention. Urgent surgery describes cases that require prompt attention—within twenty-four to forty-eight hours as I just explained. Required surgery covers conditions which must be corrected by surgery. Then there's elective surgery— this covers conditions that should have surgery, but if it is not done, there's not much danger of a catastrophe. And optional surgery covers conditions where surgery might be desirable or advisable, but not essential."

"Will you handle the surgery, Doctor?" Ben had asked.

"No. I don't do major surgery—virtually none of any kind. You may select the surgeon you'd like to have."

"Will you suggest one?"

Dr. Freund had suggested several, and the selection had been made. From the time Mrs. Edwards entered the hospital until she was released to return home, she would be under the care of the surgeon.

"How long will I be in the hospital?" Mrs. Edwards had asked.

"A week to ten days, depending upon how quickly you recover."

Now, even as Ben Edwards remembered the conversation, the surgeon made the initial incision in the operating room. The team went into action, functioning smoothly, each with his or her own task.

The surgery on Mrs. Edwards was almost routine. Within two hours she was in the hospital's "recovery room" where she received expert nursing attention until she was out of the anesthetic and could be taken to her room.

Some progressive hospitals also have what is known as an "intensive care unit" where, for an additional cost, a patient receives around-the-clock special nursing in a small ward especially equipped for the more critically or dangerously ill.

For centuries most surgery was limited to the surface of the body or to the extremities. Haggard comments upon this in Devils, Drugs, and Doctors by revealing that 43 centuries after the Egyptians engraved pictures of operations, in 2,500 B.C., surgery still was wound surgery. "In fact," Haggard observes, "there were no great advances until late in the nine­teenth century. Until that time operations were still performed only on the surface of the body, and operations still involved as much suffering, and wounds were as universally infected, as in the early Egyptian period."

Increased knowledge of anatomy, ability to control hemor­rhage, anesthetics, and ability to prevent and take care of infection all contributed to the new era in surgery.

Today the skill of surgery may be applied effectively to the eye, ear, nose, and throat; the skull, brain, spinal cord and nerves—neurosurgery; neck and chest regions; abdomen, in­cluding gall bladder, liver, pancreas, spleen, stomach and duodenum, small and large intestine, pyloric stenosis, colon, appendix, and rectum; genito-urinary region, including the kidney and ureter, bladder, prostate gland, and male genitals, female reproductive system; the extremities and conditions calling for orthopedic surgery including—in this over-all field —varicose veins, the spine, birth deformities, reconstructive surgery, fractures, amputations, and torn cartilage conditions. Then there is surgery in the area of superficial tissues includ­ing the skin, subcutaneous tissues, pilonidal cysts, cuts, bruises, burns, abscesses and infections.

Plastic surgery has increased in importance and has become highly specialized. As observed by Dr. William G. Hamm and Dr. Frank F. Kanthak, both from the Emory University School of Medicine, "Plastic surgery is primarily that branch of general surgery which is distinctly formative or construc­tive. It deals with the repair of defects and malformations, either congenital or acquired, with the restoration of function and comfort, and incidentally with improvement of appear­ance." (75 Years of Medical Progress.)

While some heart and chest operations, cancer operations, and intricate transplants and other new developments have been prominent in the news, a great amount of everyday surgery involves about four common operations of a more serious nature than the run-of-the-mill tonsillectomy and removal of the adenoids. (One of the safest operations, but not now routinely recommended for children in the three to five group. In recent years the medical profession advises the procedure—for the greater part—only when tonsils are chronically infected, or when diseased adenoids threaten or have caused nose or ear complications.)

Four very common conditions are appendicitis, gallstones, hernia, and varicose veins.

Even since the mid-Fifties, when the above observation was made, news of plastic surgery has gained increased attention.

Skin grafts for persons badly burned, or hurt in accidents, are highly successful in many cases, although efforts to graft skin from one person to another are, as Dr. Rothenberg states, "Notoriously unsuccessful." As with transplants of vital organs, the successful ones have been mainly between identi­cal twins.

However, skin may be successfully grafted from one area of a person's body to another. The grafting may be done with small pieces, about one-quarter inch in diameter, of superficial layers of the skin. A number of these—possibly a dozen or more—are taken from the donor area of the body and placed at spaced intervals in the recipient site. They grow to their new location, spreading out to cover the bare area. These are called pinch grafts and have been replaced largely by split-thickness grafts.

Actually, split-thickness grafts are sheets of superficial skin and part of deep layers of skin that are almost miraculously sliced from the donor area by a special knife instrument called a dermatone. The grafts may measure around four inches in width and twice as long or even longer.

The split-thickness grafts usually come from flat surfaces of the body such as the back, thigh, or stomach. They are espe­cially useful for covering areas where no skin exists, as in the case of severe burn damage. The grafts are sutured in place around the edges and compression bandages are placed to assure firm contact with underlying tissue. The donor site is covered with sterile dressings and heals well since only the top layers of the skin have been taken away.

Full-thickness Grafts, as the name implies, consist of all layers of skin, but not underlying fat tissue. They are most useful where they can be used on heavy friction or weight-bearing areas, such as feet and hands. The grafts are cut to fit, exactly, the bare area to be covered.

Pedicle Grafts are those grafts where one portion of the skin remains attached to the donor site while the remainder is transferred to a recipient site. The graft gets its blood supply from its attached portion at the donor site. When it develops a new circulation from its new site, then the base of the pedicle graft is detached from the original site. Pedicle grafts are useful in covering defects about the face when a wide area of skin has been removed, or to cover a hand or a finger with new skin.

Among other operations of this type are the cornea trans­plants which are successfully done from the body of a dead person to a living person. Teeth have now been transplanted. A toe has replaced a thumb.

Probably a vast part of the public thinks of "plastic" surgery in the terms of cosmetic plastic surgery that has be­come familiar to thousands in recent years.

Almost everyone has heard of the "face lift" operation. This is typical of cosmetic plastic surgery. The removal of blemishes, the reconstruction of noses, the lifting of sagging breasts are also becoming more familiar.

Face lifting operations are especially common among theater people and others who must depend upon their looks in their profession. It has gone beyond the theater, in fact, and now many other professional people, not infrequently, have such surgery performed.

It is conservatively estimated that more than 150,000 per­sons a year now submit to cosmetic surgery in this country.

A 44-year-old actress who knows that her beauty is fading, that her jaw line is sagging, that wrinkles are appearing, that there are the beginnings of pouches under her eyes, considers a face lift as a business necessity and visits her personal doctor.

They talk over the problem and he recommends one of the qualified plastic surgeons in the area and arrangements are made for the operation.

"Will it be painful?" the actress asks the surgeon.

"No. We'll use a local anesthetic. There'll be no pain."

"How long will it take?"

"The operation itself—or until you're ready to see some people again?" the doctor inquired with a smile.

"Well . . . both."

"Probably about three hours for the operation. I'll take out the stitches on the sixth day, probably. You may have some bruises still left, but possibly not. Maybe dark glasses for a few days. Blame it on a sinus operation, if you like. Some of my patients do."

"You're sure. . . ?"

"No guarantees," the surgeon tells her. "But reasonably sure—yes."

"All right," the actress agrees, "have at it, Doctor!"

On the day before the operation, the actress returns to the surgeon and he carefully studies her face while she is relaxed. Using his carefully developed technique, he draws guide lines with indelible ink. The actress is given a sedative to relax her and to allay any nervousness she may still have about the operation. Starting with a small triangle, her hair is shaved over each side, above the hairline, starting in back of the ears and crossing above the forehead, where the hair will cover it later.

The next morning she is given Nembutal by her surgeon. It puts her to sleep for about 15 minutes while he injects Novocain to serve as the local anesthetic.

The operation begins.

The surgeon makes an incision above each ear, cutting down an eighth of an inch, penetrating just to the covering over the muscle.

"Any pain?" he asks.

"None. Have you really started?"

"We're on our way."

The surgeon works carefully with scalpel and scissors. He .slowly undermines the skin, freeing it inch by inch, down past the mouth, under the jaw, to back of the ear.

His patient seems almost drowsy as he works.

"Now," he says, "we'll fit it smooth and tight again."

He refits the skin as he talks, working carefully with deft sure fingers. Excess skin is cut away in a pattern around the ear and the refitted skin is stitched in place.

"Half done," he announces. "Are you all right?"

The actress tries to speak and her eyes twinkle in a smile because the anesthetic makes speaking difficult. The doctor laughs with her. He begins to repeat the operation on the other side of the face.

In about three hours the operation is completed. Pressure dressings are applied and bandaged into place over forehead, cheeks, eyes, upper nose and chin.

"There!" he announced. "Now we wait."

Three days later the dressings are removed. The patient is a little black and blue, but the operation appears to be suc­cessful. She is sent home. On the sixth day the stitches are removed.

"You look fifteen years younger!" her husband exclaims. Her friends remark about "how young" she looks.

"A sinus operation," she smiles.

Probably her greatest relief—important psychologically— is the fact that she now can work close to a television camera without worrying about "how old" she looks.

Frequently a much less extensive—actually a minor—oper­ation is needed in about 18 months after the first to pick up some small sagging that may occur. It is much less extensive and as one patient described it: "Just a tuck to complete the job!"

Some stars—and society women and others—have had several "face lifts" and occasionally the pattern runs to one at about 40 to 45 years of age, another two to five years later (which usually lasts longer) and a third at about 60.

It is not uncommon for male actors to have the operation. Political figures and other professional men have had them, and more are considering them. Where looks are an asset, the operation may be very important, professionally as well as psychologically speaking.

The cosmetic nose operation is discussed elsewhere in this book, and it is being performed more frequently every year.

Large, pendulous breasts have been a mar to feminine beauty for young as well as old.

Several surgical techniques have been highly successful in remedying such conditions. An incision frequently is made in the fold of the lower border of each breast where scars will be better concealed. Excess fat and glandular tissue in the breasts are removed.

When such operations are done with proper care, the breasts look and feel as they should, and remain capable of functioning and producing milk for babies which the woman may have later on.

Again it is important to remember that the psychological value of such an operation may be great.

There seems to be much more medical acceptance of the operation to decrease the size of abnormally large and pendu­lous breasts than there is to increasing the size of breasts.

Here again, however, there is a demand for aid. Occasion­ally, surgeons have firmed breasts by transplanting fat from another part of the body, such as the buttocks or abdomen. Muscle from the chest wall also has been used. Results have not been entirely successful and there is a tendency for the transplanted tissue to shrink.

More recently there have been experiments With a sponge-like plastic (Ivalon) which is implanted.

A great many plastic surgeons regard such operations with doubt.

Blemishes on the skin frequently are removed by derma-brasion, in which the skin is chemically frozen so that it becomes rigid, and a dime-size steel brush, electrically driven, is applied to the blemish.

In about two weeks the "blush" or redness from the treat­ment disappears and sometimes the blemish is gone, too. In other cases the condition is improved. Chicken pox scarring,

"Port wine" stains, large and unsightly freckles, and even some wrinkles may be removed by dermabrasion.

Other cosmetic surgery is used to build up a receding chin, or trim down a jutting one; to pull back "fly-away" ears or reduce the dimensions of oversized ones. Flabby skin on underarms, and even on abdomens, has been removed.

The trend toward cosmetic surgery is increasing. With people living longer, wanting to work longer, to lead active lives longer, it is quite possible that we can look for a definite increase in the demand for such surgery in the coming years.

Although appendicitis is considered to be a relatively dif­ficult condition for correct diagnosis in many instances, the appendectomy operation is one of the easiest and, probably, safest, unless the appendix has ruptured.

The danger in the gallstone condition arises when a stone may be lodged in the bile duct and cause infection. This usually calls for an emergency operation and the condition is a threat to life.

A large number of periodicals have carried advertisements in issue after issue, year after year, extolling the efficacy of this or that truss for hernia, or rupture.

On a cold, blizzardy night of 1922, Bert Rothen, a brake-man on a railroad that crossed the Dakotas, swore as he trudged through snow beside the freight train in a small, bleak town. He stepped up on the snow-covered platform of the station and looked at a heavy-set woman approaching him in the night.

"I hope that passenger train is about due!" the woman ex­claimed. "I don't want to have to sit in that waiting room. It's almost as cold in there as out here."

"Train's about due, ma'am," he told her. "We're on the siding waiting for her."

"That's good news," she smiled, puffing a little from her fast walk to the station. She was beside Bert and was step­ping toward the station door when she suddenly slipped and began to fall.

Desperately Bert reached for her and slipped. For a few seconds he strained to hold her full weight, even as he tried to catch his footing, and before they both crashed to the platform.

He helped the embarrassed woman up and they both laughed at the incident. Bert had noticed a quick pain in his groin as he fell, but thought he probably had strained a liga­ment as he went down.

Later, sitting in the warmth of the caboose as the train roared westward through the storm, he realized that there was a definite soreness in the groin.

He stayed overnight at the division point and returned home the following night. Before he took another run, he noticed a bulge beneath the skin at his groin when he was dressing. That night he questioned the head brakeman, Matt Isaacs, as they journed again through a winter night.

"Say, Matt, don't you have a rupture?"

"Had one for years. Inguinal hernia, the doc calls it. Thinks I ought to have it operated on, but not me. I wear a truss."

"How does it work?"

"You mean how does it hold the hernia in place, or do I like it?"

"Both, I guess."

"Okay. It's sort of like a pad. It keeps the intestine inside where it belongs. That's what happens. You've got a sort of lining in there. In some places it's weak. You strain yourself and it gives way. Part of your intestines forces its way out in a kind of sack."

"And the truss keeps it back where it belongs?"

"That's the idea. Why, Bert? You got a rupture?"

"Well, I've got a bulge down there."

"Better see a doc."

"Where did you get your truss?"

"Drugstore. Old Man Harton. But you better see the doc."

Bert followed Matt's advice and saw the company doctor. The condition was confirmed. Surgery was suggested, but Bert demurred.

"Can't I get a truss?"

"You can, but they're not always satisfactory, Bert."

"I'd rather. I don't want the operation."

"That's up to you. I'd recommend the operation, but it's your hernia, Bert."

Bert wore a truss, putting up with the inconvenience of it for thirty years before the appliance failed in its function and Bert was in trouble.

This time he listened to a doctor's suggestion. He entered a hospital and underwent surgery. Three months later Bert was walking with his wife when he suddenly looked at her and smiled wryly.

"I'm crazy, Letty," he said. "I should have had it done thirty years ago. Matt and his truss and his big mouth."

"He told you to see the doctor then, Bert. So don't be blaming Matt. He is your best friend."

"I think I'll see if I can talk him into an operation," Bert laughed. "He's always beefing about that truss he wears."

Hernia operations are usually very successful for both men and women. There are several types of hernia and a great many doctors say that a vast majority of them should be repaired. They are seldom dangerous or painful.

Almost any woman knows about varicose veins that may disfigure the legs. Most women—probably all women—des­perately hope they will never be disfigured by them. A great many women are.

For a time the only treatment was through injection. This system earned a reputation of being dangerous and unsatis­factory.

A second system involves tying off veins at their roots in the groin. This system brings only temporary relief because the trouble is likely to recur.

The latest treatment is called ligation and stripping. The vein and its branches are cut in the groin. Then a wirelike instrument, appropriately called a "stripper," is run through the full length of the vein, from groin to ankle. At the lower point an incision is made. The vein is tied to the upper end of the wire and stripped out through the lower incision by pulling the wire. Results are reported to be excellent.

Lung surgery has taken important strides forward owing to the improved safety offered by modern anesthetics. Most surgeons appear to agree that the hazards are not much greater, or no greater, than in abdominal surgery.

Transplants have been almost astounding in their daring. Recent kidney transplants in twins appear to be successful, and in October, 1960, a team of Stanford University doctors described to a convention of the American College of Sur­geons how they successfully had transplanted whole hearts from six dogs into other animals.

Similar experimental animal transplantations are reported involving the stomach, liver, spleen, small bowel, colon and other organs.

Surgeons hope to be able to give patients new hearts, kid­neys, adrenal glands and other organs, eventually. They would be taken from newly dead people whose organs were healthy and functioning.

Probably no field of surgery has had more attention over the last few years than in the heart operations. Now the open-heart operating techniques are becoming almost com­monplace in medical centers across the nation. Heart-lung machines carry on the heart's function while surgeons work on the heart. Plastic parts replaced damaged human organs. A man-made heart valve efficiently works when the natural valve fails. More and more lives are being saved every month through the aid of heart operations.

Brain surgery may be illuminated in the layman's concept by a single sentence written by Dr. Emanuel H. Feiring in his contribution to Understanding Surgery: "Progress in sur­gical technique has made it possible to gain access to almost any part of the brain with reasonable safety!"

Obviously the important progress in medicine includes the accomplishments in the specialized field of surgery. And here, too, the future is bright with startling new developments just beyond the horizon or already in view.

ANESTHESIA—It is obvious that the modern uses of anes­thetics enables the surgeons of today to operate with such skill and success.

Although there are a number of historical references to various approaches to the answer to pain, and a soporofic that might make surgery less of an ordeal, it was not until 1846 that ether was used and the era of modern anesthesia was introduced.

Previous to that time patients confronted with surgery were tied down with ropes, held by strong men, and occasionally drugged with alcohol or opium. Their shrieks of agony ac­companied the ministrations of the surgeon, while the strong muscles of attendants and the relentless bite of ropes held the patient steady beneath the surgeon's knife.

Around 1844 nitrous oxide (laughing gas) made an im­pression upon the public, but largely as a source of enter­tainment. "Grand exhibitions" were given to which admission was charged and at which, as an old poster reads: "GAL­LONS OF GAS will be prepared and administered to all in the audience who desire to inhale it. MEN will be invited from the audience to protect those under the influence of the Gas from injuring themselves or others. This course is adopted that no apprehension of danger may be entertained. Probably no one will attempt to fight. The effect of the gas is to make those who inhale it, either LAUGH, SING, DANCE, SPEAK OR FIGHT, &c. &c."

A notation toward the bottom of the poster warns: "The Gas will be administered only to gentlemen of the first respec­tability. The object is to make the entertainment in every respect, a genteel affair."

In 1844 a dentist from Hartford, Connecticut saw one of the demonstrations and subsequently tried it in an attempt at a painless extraction of a tooth. However, it did not come into use as an anesthetic agent until 1868.

In 1853 Queen Victoria accepted chloroform during labor, and again 4 years later.

Today anesthesiology has become an important field in itself. Even the memories that some individuals may have of a number of years ago when a mask was suddenly clamped over the face and the anesthetic poured into a cone until unconsciousness came are very much a part of history now.

Nor do those who experienced the pain of the needle in the first instances of spinal anesthesia need fear a repeat performance today.

Premedication begins the anesthesia, frequently from Pen-tothal injected into a small vein of the arm or hand. Or local injections of Novocain make the spinal anesthesia almost painless.

New anesthetics make their appearances, and old ones continue to do excellent jobs. Anesthesia varies for various operations. Sometimes a general anesthetic is employed. Sometimes only a small part of the body is affected. Occa­sionally, with a regional nerve block anesthesia, the patient converses with the anesthesiologist or doctor through the full operation without experiencing pain.

When inhalation anesthetics are used, generally for major surgery, the anesthetic agents are used in combination with oxygen.

Such anesthetics include nitrous oxide, cyclopropane, ether, ethyl chloride and divenyl oxide. Intravenous drugs frequently used include Pentothal, Evipal, and Surital.

As noted above, anesthetics are given today, preferably, by a doctor-anesthetist when one is available. However, nurse-anesthetists who have been well trained and are competent can be safely used in the absence of a physician.

Even as the use of drugs and gases as anesthetics approach maximum effectiveness and safety, they may soon be over­shadowed by a completely new type of anesthesia.

Early in 1961 a woman was taken into an operating room at the University of Mississippi medical center. She had received the usual preanesthetic medication, but there the procedure departed radically from the usual.

The customary airway tube was skillfully inserted into the throat of the patient while she was still awake. The tube pre­vents strangulation when the patient is unconscious.

Now two electrodes, the size of half dollars, were placed at the woman's temples. The surgery team was ready. This was the moment that climaxed four years of research and work at the center under a grant from the Army.

A switch was turned on. An oscillator—frequency gener­ator—sent 700 cycles of current through an amplifier and to the electrodes. In less than a minute the woman was asleep and the surgery team proceeded with the operation. As long as the 700-cycle signal was provided to the patient, she would remain asleep.

The operation was finished. The switch was turned off. The patient was awake almost immediately. There was no nausea or other aftereffects. There was no need to spend hours in the recovery room. The first use of electrical anesthesia in the United States, and possibly in the world, was a success.

Anesthesia had truly come of age!

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