Some 
Unsolved Problems 
in Surgery 
BY 
W. W. KEEN, M. D., LL. D. 
REPRINTED FROM 
THE SATURDAY 
EVENING POST 
I9°7 Copyright, 1907, by 
The Curtis Publishing Company Some Unsolved Problems 
in Surgery 
By W. W. KEEN, M. D., LL. D. 
IN THIS paper I shall attempt to describe as clearly as 
possible some of the unsolved problems of surgery. 
President Eliot's recent advocacy of giving such 
information to the public is an indication of the correct 
attitude which specialists in various branches of knowl- 
edge, I think, should assume. 
There are four different methods of producing anes- 
thesia : 
(a) General anesthesia by the inhalation of ether, 
chloroform, nitrous oxide gas, chloride of ethyl, etc., or 
by the hypodermatic use of drugs, such as scopolamin and 
morphin. 
This is the only method in which the patient is rendered 
entirely unconscious. In all the three other methods con- 
sciousness is retained, the loss of feeling being limited to 
a larger or smaller localized area. 
(b) Local anesthesia by freezing or by subcutaneous in- 
jection of drugs such as cocain, eucain, Schleich's fluid, etc. 
This produces a loss of feeling in the injected area only. 
(c) Spinal anesthesia by the injection into the spinal 
canal (that is, in the "small of the back") of various solu- 
tions, such as cocain, eucain, stovain, etc. This produces 
entire loss of feeling from below the waist to the feet, and 
the effect may extend even higher. 
(d) By "neutral infiltration "-that is, exposing the 
nerves supplying the parts of the body to be operated 
upon, especially the hand, arm or leg, and injecting into 
the substance of one or more nerves, going to the part to 
be operated upon, a solution of cocain. By this method, 
the whole of the parts supplied by these nerves are ren- 
dered anesthetic. 
3 One of the most important uses of this method has been 
shown by experiments upon animals to be the prevention 
of severe shock. In many cases now on record this has 
been applied to man and not a few lives have been saved 
by it. When such an operation as removal of the whole 
leg at the hip-joint or of the arm at the shoulder-joint had 
to be done, it was found that, even with the patient under 
ether, when the great nerves going to the arm or leg were 
divided there was very severe shock to the whole system. 
But if, before these nerves were divided, a few drops of a 
solution of cocain were injected into them above the point 
where they were to be cut, no such shock resulted, since 
the sensory influences passing through the nerves to the 
spinal cord and brain were "blocked" by the anesthetic 
effect of the cocain. 
But all these various methods or drugs have a small but 
certain percentage of danger. Nitrous oxide has the lowest 
death rate. In a series of 241,032 cases, only one death 
occurred. But practically, except for brief operations, 
such as opening abscesses, nitrous oxide is but little used 
in surgery. 
Ether and chloroform, the two general anesthetics most 
often used, have the following death rate: 
Anesthetic 
Total number of 
administrations 
Total num- 
ber of deaths 
Death rate 
Chloroform* 
691,319 
224 
1 in 3082 cases 
Ether 
407,553 
25 
1 in 16,302 cases 
Even the local injection of cocain will sometimes intoxi- 
cate and sometimes, though rarely, will produce death. 
Spinal anesthesia is desirable in certain cases, but is by 
no means free from danger. 
The multitude of methods and of drugs is a witness to 
the active search of surgeons for safer and better methods. 
The ideal anesthetic for grave operations is not, as 
might be supposed, that which leaves the patient per- 
fectly conscious. In most cases he would be terribly 
scared by the sight of blood, and if he were aware of the 
♦These are largely from European clinics in which chloroform is 
much more commonly used than in America, where ether is generally 
preferred. 
4 surgical emergencies of hemorrhage or other dangers 
which may test all the resources of the surgeon, he might 
be alarmed even to the point of collapse. A nervous pa- 
tient would be easily and needlessly alarmed by hemor- 
rhage which to the surgeon would be mere child's play. 
I am often amused at the recollection of my first operation 
on a'soldier in 1862-as I look on it now, a very simple one. 
At the first incision my heart went pitapat, for I was sure 
he would bleed to death before I could tie the arteries! 
How much more easily then would a patient be frightened. 
The ideal anesthetic is that which will abolish pain and 
also consciousness, but without any danger to life. Such an 
anesthetic will surely be found. Its advantages are so 
obvious as not to need further recapitulation. 
Until this safe anesthetic is found surgeons are endeavor- 
ing to find the best means of resuscitating the patient when 
even apparently dead. In animals much has been done to 
show that we can avert the dangers, especially of chloro- 
form. Last May at the meeting of the American Surgical 
Association in Cleveland, Doctor Crile showed some mar- 
velously successful experiments upon this subject which 
I had the pleasure of witnessing. In one of them a dog 
was killed by a large dose of chloroform. Fifteen minutes 
by my watch after the heart had ceased beating and after 
breathing had entirely ceased, a tube was inserted into a 
blood-vessel and a solution of salt and water of suitable 
strength, together with a little adrenalin (a preparation 
described later), was allowed to flow into the blood-vessel 
toward the heart. After a few moments the chest was 
compressed to start the heart beating, and almost on the 
instant breathing was resumed, the heart began to beat 
regularly and within less than five minutes the dog had 
recovered. Up to eight minutes after apparent death 
animals can nearly always be resuscitated, and, even when 
the dog has been dead for twenty-five minutes, temporary 
resuscitation has been achieved. 
In a few cases in which death from chloroform collapse 
has occurred in man the heart has been exposed and started 
beating again, and life has been saved by quickly opening 
the chest, seizing the heart by the hand, and rhythmically 
5 squeezing it. Unfortunately by this method far more 
failures than successes have been published, but as a result 
of Crile's experiments it is likely that we may be much 
more successful in the future. 
Infected Wounds. Let me name two such wounds as 
types. 
(a) By a fall, a trolley-or a machinery-accident a 
man suffers a "simple" fracture-that is, a fracture in 
which the bones are broken but the skin is intact. Such 
a "broken arm," or "broken leg," as everybody knows, 
heals within a reasonable time and with almost no danger 
to life. But, if the bone protrudes through the skin, it 
produces a "compound" fracture. Such a wound before 
the days of antiseptic surgery (say before about 1876) al- 
ways became inflamed by inevitable infection by the germs 
on the skin, in the clothing, etc. By exhaustion from pain, 
fever and prolonged discharge of pus ("matter"), by 
blood-poisoning or erysipelas, compound fractures at that 
time killed about two out of every three patients. Now 
the mortality of such fractures is less than one per cent. 
(b) A stableman steps on a rusty nail. Soon afterward 
lockjaw (tetanus) develops. Before 1887, unless he re- 
ceived proper surgical care, death was almost inevitable. 
It was in that year Nicolaier discovered the germ (bacillus) 
of lockjaw in the earth, and found that the earth around 
stables, and in streets, was especially full of them. This 
explained the long-known frequency of lockjaw in people 
having to do with stables, horses and cattle. Every now 
and then it followed operations and was very fatal. Of 
505 cases in the Civil War, 451 died, a mortality of over 
89 per cent. Nowadays lockjaw after operation is almost 
unknown, but it still occurs after accidents causing open 
wounds when not properly treated. 
Inflammation, blood-poisoning and death are the fre- 
quent consequences of accidents which are not at once 
seen by a competent surgeon. 
Why do these differences exist? The reason is now very 
well known and seems simple; but the means by which 
the dreadful results of such accidents have been banished 
are the fruit of unceasing toil for years in the laboratory, 
6 of repeated illuminating experiments upon animals, of 
many failures, but of final success. 
When an operation is to be done the area of operation, 
the instruments, dressings, and the hands of the surgeon 
and every assistant and nurse are made thoroughly aseptic 
-that is, germ-free. Thus even a dangerous operation 
can be done and speedy recovery follow with no fever, no 
pus and but little pain. In case of an accident, if the sur- 
geon sees the case promptly he will etherize the patient, 
and will scrub and cleanse not only the skin, but the very 
depths of the wound for a long time, so as to make it 
aseptic. Generally he will succeed and speedy recovery 
will follow. 
But suppose he does not see the case promptly. Then, 
the germs will have invaded the tissues and even the 
blood, and the problem then becomes one of extreme dif- 
ficulty-how to destroy the germs and yet not do harm 
to the patient. Many antiseptics have been tried, but, if 
weak enough not to kill the patient, they do not kill the 
bacteria, and solutions strong enough to kill the bacteria 
are inadmissible, because they would kill the patient. 
How to disinfect a thoroughly infected wound is one of 
the most puzzling and baffling present-day problems of 
surgery. Its solution will come eventually, but only by 
repeated and well-reasoned-out experiments upon ani- 
mals. To be able easily and effectually to disinfect 
wounds in full tide of suppuration means a blessing to 
mankind, and to animals as well. 
Meantime, the lesson is obvious. In any case of acci- 
dent with an open wound it is of the utmost importance 
that the surgeon shall see the case as soon as possible. 
Twenty-four hours' delay often means dangerous illness or 
perhaps death. 
But, while waiting for the surgeon, can nothing be done? 
Surely. Cleanse the parts with cloths that have been 
boiled, and water that has been boiled and cooled enough 
to be bearable. The only antiseptics probably available 
will be alcohol (not wood alcohol, as that is poisonous) 
used pure, or whisky, brandy or wine. This should be 
used to wash the parts thoroughly, and boiled cloths, 
7 wrung out of the same or out of boiled water, should pro- 
tect the wound pending the surgeon's arrival. 
Probably no disease, not even tuberculosis, is being 
attacked with such vigor and all along the line as cancer, 
in order to discover its cause and its cure. As yet, it is 
sad to confess that the cause is not known. Cure, however, 
in the majority of cases, can be attained. 
The problem of the origin of cancer is being attacked in 
various countries; at the special cancer laboratories in 
Buffalo and Boston, and the Rockefeller Institute for 
Medical Research in New York; in the various cancer 
laboratories in London, Berlin, Heidelberg and elsewhere 
in Europe, and in many ordinary laboratories all over the 
world. It is being attacked by the microscopist to find any 
specific cell or germ or parasite which may cause it. It is 
being attacked by the chemists to see if there is any pecul- 
iar chemical reaction or agent or compound discoverable 
in specimens of cancer. It is being attacked by the exper- 
imenter to see if, by inoculations in varying ways and 
under varying conditions into animals of various species, 
the cause may be discovered. 
But thus far, in spite of an enormous amount of work 
by the shrewdest thinkers, investigators and experiment- 
ers all over the world, the quest has been fruitless. No, 
not fruitless, for we have learned what means and what 
methods will not solve the riddle, and that, therefore, our 
investigations must be made in other ways. 
Shall we ever find out the cause ? Assuredly yes. I can- 
not even believe that the solution of this dreadful problem 
will long be delayed. Once the cause is found, we can 
attack the problem of cure from a far more advantageous 
point, and the treatment, especially the preventive treat- 
ment, will become more intelligent and more efficacious. 
Very possibly it may banish the knife-a consummation 
devoutly to be prayed for, and one which will be welcomed 
by no one more heartily than the surgeon, for his daily 
life is constantly saddened by having to treat so many of 
these hopeless cases of suffering. 
But cure, practically a permanent cure, is even now 
obtained in the majority of cases. This welcome news 
8 should be diffused throughout the community, especially 
among women, who suffer so much more frequently than 
men. This cure is attained by early and thorough removal. 
Note that two elements are needful for this happy end. 
First, early removal. The chances of cure are immensely 
increased by early operation. Deferring the operation 
only gives time for the disease to invade the tissues more 
widely and to taint the whole system, for cancer at its 
beginning is an entirely local disease and it requires some 
time to infect the system. This factor in the cure is wholly 
dependent on the patient. Pain-it is of the utmost 
importance to impress this idea upon the community- 
Pain has nothing whatever to do with the danger of any 
such lump. A cancerous lump may be of the most malig- 
nant character and yet the patient may suffer no pain for 
many months. The rule should be invariable; whenever 
you discover any lump anywhere, painful or painless, seek 
the surgeon-not necessarily for his knife, but for his 
advice. It is for him to determine whether the lump is a 
cancer or not. If it is a cancer, at the present time no 
treatment other than operation-except in a very few 
cases, of which the surgeon will be the best judge-should 
be considered. All drugs, quack doctors, salves and such- 
like simply delay the final treatment, often until it is too 
late. The X-Rays, in some cases of superficial cancer, 
do good; possibly the Finsen light may prove useful. 
But these means are applicable only to exceptional cases. 
The second element necessary to success is thorough 
removal. This is the surgeon's duty. The incomplete 
operations done, say before 1890, were nearly always fol- 
lowed by recurrence. The thorough operations done since 
then show cures of over 50 per cent. Early operation 
gives even a better percentage of cures. 
In one form even of inoperable malignant disease - 
sarcoma, as distinguished from true cancer-we can occa- 
sionally obtain benefit, but rarely a cure, by the injection 
of a preparation of the germ of erysipelas. It might be 
termed "setting a thief to catch a thief." 
The late Rev. Dr. George Dana Boardman, my own 
dear friend and pastor, often and most impressively 
9 said to me: "Depend upon it, you will find that the 
statement of Holy Writ-'the blood is the life thereof'-in 
years to come will be found literally true." The last ten 
or fifteen years are proving that he was a true prophet. 
But the problem has been so recently attacked that it has 
not yet been half solved. 
The blood has been and still is being studied in two ways: 
(1) The pressure of the blood as a fluid flowing in flex- 
ible tubes (the arteries and veins), and (2) the various 
normal and abnormal elements found in the blood itself. 
The whole subject is most fascinating and as interest- 
ing as any romance, but to do more than merely indicate 
a few points of surgical importance is impossible. Even 
these must be treated in a most superficial way. 
1. Blood pressure. Accurate knowledge of the exact 
pressure under which the blood circulates in the blood- 
vessels, exactly as water does in a city's water-supply 
pipes, can only be obtained by inserting a tube into an 
artery or vein, and connecting this by a rubber tube with a 
glass tube containing mercury. The height to which the 
column of mercury is pushed up shows the blood pressure. 
By this means, in many different blood-vessels and under 
many different conditions, the actual facts have been 
ascertained. Evidently this method can only be adopted 
on animals. Very ingenious instruments, however, have 
been devised to obtain the blood pressure in man-in 
health, in various disease and after accidents-with 
approximate accuracy and without such an operation. 
The instruments are usually applied to the artery in the 
arm above the elbow. 
The practical results of these studies in animals and 
man have been of great value. We now know-instead of 
guessing at it -that one of the great dangers of chloroform 
is its effect on the blood pressure; that a large blood clot 
on the brain raises the pressure to a degree dangerous to 
life, that the degree of blood pressure is an index of the 
pressure inside the head, and that operation for the re- 
moval of the clot removes the chief danger; that in ab- 
dominal operations, as shown by operations upon animals, 
our manipulations of the contents of the abdomen must 
10 be as gentle and as restricted as possible-a new lesson to 
many a surgeon and a life-saving lesson for many a patient. 
Until this was shown by such experiments surgeons never 
dreamed that they were doing harm by such manipula- 
tions. Did time permit, many other applications of this 
new knowledge could be given. The study of this problem 
has begun so lately that our knowledge is, as yet, very 
imperfect. 
2. Even of greater interest and value are the studies of 
the last ten years of the blood itself by the microscope and 
other means of investigation. 
The blood is made up of a fluid in which float the blood 
corpuscles or blood cells. These last are of two kinds, the 
red, which carry the oxygen from the lungs to all parts of 
the body, and the white cells (or leucocytes). In a cubic 
millimeter of blood (that is, a cube whose side is 1-25 of an 
inch) there are usually about 5,000,000 red cells and only 
7500 white cells. In inflammations, however, such as 
abscess, appendicitis, etc., the white cells rapidly increase 
in number up to 15,000, 25,000 or even 50,000 or more in 
the cubic millimeter. This increase (calk d leucocytosis) 
seems to be an index of the degree of the infection ana of 
the resisting power of the patient to the poison of the 
infection. The severer the infection, the greater will be 
the increase in the white cells. But if the infection be so 
severe as to overwhelm the patient, then there will be 
little or no leucocytosis. If the patient is in vigorous 
health and makes a fierce fight for life the white cells 
show a large increase; but if his health is poor and his 
powers of resistance feeble the increase will be but slight 
and he loses the battle. 
It must be understood, of course, that these statements 
-as many others in this paper-are dogmatic and are not 
intended to be interpreted too exactly, for there are many 
other factors which would modify the statements, and 
these must be taken into account. For popular explana- 
tion, however, these modifications may be neglected. 
Sometimes, by the blood count (that is, the numbers of 
the red and white cells), we can distinguish between dis- 
eases which may be very similar in their initial stages and 
11 yet require very different treatment. Thus, in typhoid 
there is no leucocytosis (increase in number of white cells) 
at the beginning, but in appendicitis there is. In the latter 
case prompt operation is generally required; in the former, 
operation would be a terrible mistake. 
But the blood also may contain germs which are wholly 
foreign to normal blood. Within the last five years, by 
improved methods, it has been found that in over 80 per 
cent, of patients with typhoid fever the germs of typhoid 
are found in the blood in the first week. Indeed, this is 
now the earliest positive means of diagnosticating that 
disorder. So, too, in that most dangerous infection, 
anthrax or wool-sorter's disease -a very fatal disease con- 
tracted from cattle-the anthrax germs are found in the 
blood at a very early stage. 
A very curious discovery has been made only within the 
last three of four years by Wright and Douglass, of Eng- 
land, as to the relation between the white cells of the 
blood, the bacteria and certain substances found in the 
blood, to which they have given the name of opsonins. 
(The accent is on the long "o" in the second syWable.) 
It has long been known that the white cells eat up bac- 
teria. When, by an infection due to bacteria, an inflam- 
mation occurs, the white cells at once increase in number 
at the point of infection and eat up the bacteria. ("Eat 
'em alive," in the words of Herr von Barwig.) If the white 
cells get the upper hand the bacteria are destroyed and 
the patient gets well. If the bacteria win the fight the 
patient dies. 
Wright and Douglass, however, have shown that in cer- 
tain conditions the white cells, so to speak, are very hun- 
gry, and will eat up the bacteria with avidity; in other 
conditions the bacteria do not seem to be attractive to 
them and they eat up very few. Thus, in ordinary blood 
25 white cells have been found capable of digesting (or 
eating up) 413 bacteria; whereas in the blood of a diabetic 
patient 25 white cells only digested 249 bacteria, only a 
little over one-half of the former ratio. The opsonins 
have the faculty of preparing (or, to carry out the figure 
of a meal, of cooking) the bacteria so that they become 
12 very attractive to the white cells, which then greedily 
feed upon them-much to the advantage of the poor sick 
fellow. By hypodermatic injections of certain prepara- 
tions we can add to the opsonic power of the blood, so that 
the white cells will do their best to destroy the bacteria 
and so help the patient out of his peril. 
But this is all so new that we cannot say positively that 
it is as yet accepted by the majority of investigators as 
well established. Yet it seems to be true, and, if it be 
proved to be so, it will make one of the most striking 
advances in modem surgery, and give us a new weapon 
with which to conquer disease. 
Internal Secretions. There are in the body certain glands 
which have no tube or duct by which the secretion of the 
gland is discharged into the blood. Among these is the 
thyroid gland in the front of the neck (the enlargement 
of which produces a goiter); another is a gland (the 
adrenal or suprarenal gland) which is situated on top of 
the kidney; and some other glands which need not be 
mentioned. The internal secretions of these glands in 
some way gain access to the blood, and, it is believed, 
influence the nutrition or other conditions of the body in a 
way essential to health. Removal of all of the thyroid 
gland in man produces a peculiar deleterious change in 
both the physical and mental condition of the patient. 
Hence, in operations for goiter, we always leave a portion 
of the gland. The effect of their removal in animals has 
been found to be similarly injurious. 
From the thyroid gland, the adrenals, and other glands 
of animals there have been prepared substances which, 
when administered to patients, produce important effects 
in various ways, so that they are now regularly used as 
medicines of recognized value. The extract of the adrenal 
(called adrenalin), as has already been stated, increases 
markedly the blood pressure and is of great value in 
certain surgical emergencies. 
But these preparations, or remedies, also have their 
dangers. Adrenalin, for instance, if injudiciously given, 
will alter the walls of the arteries and produce senile 
changes. 
13 The wise use of these agents is as yet largely an unsolved 
problem in surgery. Experiments upon animals, to which 
they can be given under known and well-regulated condi- 
tions, and clinical observation when they are used on man, 
will "serve in time to clear up much that is as yet imper- 
fectly understood, and guide us in their proper use so that 
we can alleviate human suffering and ward off disease or 
even death itself. 
Experiments on the Blood-vessels. Until lately, when a 
blood-vessel was cut, our only resource was to tie it so as to 
prevent fatal hemorrhage; but as this cut off the entire 
blood supply of a leg or an arm it was not seldom followed 
by gangrene. In the last few years, however, by experi- 
ments upon animals, we have learned how to sew up the 
openings in such vessels. Even when the blood-vessel has 
been completely cut across we can now sew the ends to- 
gether, thus restoring the continuity of the artery or vein, 
and preventing the gangrene which might otherwise 
follow. More than that, as a result of many such experi- 
ments, Carrel and Guthrie, in Chicago, have been able 
entirely to remove a kidney and then replace it, sewing 
the cut ends of the artery and the vein, each to each, and 
the kidney has resumed its normal function. They have 
even been able, successfully, to take one kidney from each 
of two dogs and replace each kidney in the wrong dog. 
They have also successfully sewed the cut end of an artery 
to a vein and vice versa. Whether it will ever be possible 
to remove a man's diseased kidney and replace it by that 
of an animal is as yet uncertain, but, per se, it is not 
impossible. 
But the result of their experiments will eventually save 
not a few limbs and lives by our ability to continue the 
blood supply to a limb in cases of aneurism. An aneurism 
is a bulging or dilatation of an artery most frequently seen 
behind the knee. Up to the present time our means for 
remedying this have been practically restricted to tying 
the artery, thus cutting off the blood supply. These inves- 
tigators have shown, however, that the vein can serve the 
purpose of an artery and the artery the purpose of a vein 
by crisscrossing them, and a Spanish surgeon, in a case of 
14 aneurism of the leg, has recently made the vein of the leg 
serve the same purpose as the artery by attaching the 
artery above to the vein below. By this means the blood 
goes into the artery for a certain distance, then goes to the 
leg by the main vein and finds its way back by other sub- 
sidiary veins. In time, the usefulness of these experiments 
will probably be immensely increased. 
In this brief paper I have been able to indicate only a 
few of the most important unsolved problems in surgery, 
and only those which lend themselves best to a popular 
exposition to intelligent non-surgical readers. Many 
others equally important, but more technical, are crowding 
upon us for solution. Happy the young surgeon who can 
aid in the solution of these important, these life-saving 
problems. 
I know of no more touching, no more reverent attitude, 
than that expressed by the late Major Walter Reed, of the 
United States Army, whose labors in discovering the cause 
and the means of prevention of yellow fever are so well 
known. It is the attitude of every seeker after truth in the 
profession I love so dearly and to which I have given the 
labor of a long life. Writing to his wife, on December 31, 
1900, he utters this noble sentiment, with which I may 
well close: 
Only ten minutes of the old century remain. Here 
have I been sitting, reading that most wonderful book, 
LaRoche on Yellow Fever, written in 1853. Forty- 
seven years later it has been permitted to me and my 
assistants to lift the impenetrable veil that has sur- 
rounded the causation of this most wonderful, dreadful 
pest of humanity and to put it on a rational and scien- 
tific basis. I thank God that this has been accomplished 
during the latter days of the old century. May its 
cure be wrought out in the early days of the new! 
The prayer that has been mine for twenty years, that 
I might be permitted in some way or at some time to 
do something to alleviate human suffering, has been 
granted! 
Major Reed's hope was speedily realized. Yellow fever 
has been practically eradicated from Cuba and Panama, 
after nearly two centuries of destruction of human life. 
15