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WO Americans, brothers, Dr. William J. Mayo and Dr. Charles H. Mayo, have perhaps the most complete surgical "plant" in the world. They are probably the best known of all living surgeons and their methods are studied by men who come from all parts of Europe solely to see them operate. An American, Dr. George W. Crile, is probably the foremost living authority on surgical shock and on transfusion of blood. Americans created the modern art of orthopedic surgery surgery to correct deformities - and are the most distinguished practitioners of the art. Dr. Harvey Cushing, another American, is perhaps the greatest of living brain surgeons. And an Americanized Frenchman, Dr. Alexis Carrel, working in an American laboratory, has opened the way to a revolutionary advance in medicine through the surgical treatment of diseased and worn out tissue. Such are only a few of America's contributions.

But, great as is the work that America has done in modern surgery, it is only a conspicuous part of an amazing whole. Here are some of the astonishing items: A finger that has been completely severed from the hand can be restored so that the full use of it is recovered; tissues that under old methods would be dead and useless can be revived by the application of intense heat; a wound of the heart can be sewed up as simpler wounds are sewed; a blood clot in the great artery of the lung can be removed; the bronchial tubes can be electrically lighted and cleared of dangerous obstructions; the brain can be freely treated by surgical means; and joints and

even vital organs may be transplanted from one body to another and continue to perform their normal functions

It is appropriate that Americans should play an important part in surgery, for it is distinctly a modern art. Indeed, it owes its origin to an American discovery. It was not until that famous day in 1846, when Dr. John C. Warren, at the Massachusetts Hospital in Boston, performed the first major operation under anesthesia, that modern surgery really began. The actual founder of the science was the American dentist, Dr. William T. G. Morton, who anesthetized Dr. Warren's patient, using a secret fluid which he called "Le theon," but which, it afterward appeared, was sulphuric ether. This beneficent vapor not only relieved the patient from al suffering but permitted the surgeon to operate as long and as freely as he would

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Great as Morton's discovery was, however, surgical procedure was still far from ideal. Blood poisoning and gangrene almost inevitably set in upon the exposed wounds. Suppuration was so much the routine sequence of operations that the medical scientists of fifty years ago regarded it as essential to success. The doctors even had a phrase, "laudable pus," which expressed this conviction. conditions that prevailed in the hospitas when Lister began his work are incredible. English surgeons operated in frock coats. Frenchmen made an operation a gala occasion, putting on dress suits. Their idea i surgical cleanliness consisted in washing their instruments in warm water. If a surgeon dropped his knife on the floor be would pick it up, wipe it on his sleeve, an

plunge it into the wound again. It was Lister's work, introducing antiseptic methods, that drove gangrene and "laudable pus" out of the hospitals. Modern surgery, which has substituted asepsis for antisepsis-the prevention of blood poisoning rather than its cure after it has gained entrance to the wound - has made practically perfect the great science of hospital cleanliness.

One thing still remained to be done. Anesthesia and asepsis are really gifts from Heaven; surgical operations, however, are not yet absolutely safe. There is one terror that still stalks about the wards; the catastrophe which has been somewhat vaguely known as "death from shock." "The operation was successful, but the patient died;" the lay mind has always regarded this expression as a somewhat grim surgical joke. However, it expressed a profound scientific truth. When patients die, in spite of perfect aseptic conditions and the finest surgical skill, they usually die from "shock.'

What is death from shock? The first man to formulate a comprehensive and intelligible definition is one of America's most famous surgeons, Dr. George W. Crile, of Cleveland, O. According to Dr. Crile there is really no such thing as surgical shock considered as a distinct phenomenon; the accident that takes place on the operating table is simply another manifestation of one of the commonest facts of everyday experience. When we laugh or cry or are frightened, or suffer any form of physical injury, however slight, we undergo some degree of "shock." A Marathon runner, after the race is finished, is suffering from "shock." No baseball No baseball player finishes a game without experiencing the same discomfort. A barefoot boy who steps on a sharp stone and hastily withdraws his foot is mildly "shocked." A soldier whose leg is torn off by a cannon ball is "shocked" on a more terrible scale.

In a word, "shock" is really another name for cerebral exhaustion. The cells of the brain when in its normal condition are richly stored with "energy." This energy is not psychical, but physical; it is composed of certain definitely known chemical constituents; it is just as real as

the steam in the boiler, or the electricity generated by the dynamo, or the air we breathe. The brain cells have an allotted supply; as they give it off, they lose vitality and weaken; if they give off all their energy or even abnormal quantities of it, they die. Nearly all physical and emotional phenomena make certain drafts upon this reservoir of energy. Fear and bodily injury in particular draw upon it. The amount of energy released depends upon the intensity of the fear and the severity of tissue lacerations. Your body could be sliced by a sharp razor and produce only a slight cerebral exhaustion; but tearing, crushing, and slashing make heavy demands upon this stored-up energy. Actual experiments conducted by Dr. Crile have demonstrated that bodily injury and emotional excitement, especially fear, produce identically the same injuries upon the brain. The brain of a fox that has been submitted to severe physical injury displayed, when placed under the microscope, exactly the same lesions. In both cases the brain-cells have given out large quantities of energy, released, that is, certain chemical substances indispensable to life. In both cases the brain has been "shocked".

In all surgical operations these two phenomena, fear and the wounding of tissues, are the elements that produce shock. The fear, of course, is preliminary; the long anticipation, the presence of the surgeon and the nurses, the sight of the operating theatre and the instruments, the suffocation produced by inhaling the nauseous ether. This latter experience especially agonizes the patient and makes serious demands upon the stored-up energy in the brain. Once anesthetized, however, we might suppose that the danger from the shock is over. That part induced by fear is, but now the more serious dangers appear. Every time the surgeon's knife goes in, the brain cells give up certain instalments of their energy. The anesthetic does not interfere with this exhausting process. The motor nerves which carry these impulses from the brain to the wounded areas are just as active as when we are wide awake. All that the anesthetic does is to make us insensible to pain; the physical results of the wound are just

as palpable as though we felt them. If we should anesthetize the condemned murderer before hanging, he would suffer no physical discomfort; the practical result, however, would be the same. That is all That is all that an anesthetic does in a surgical operation. Sometimes the body, even under deep anesthesia, gives evidences of the injury to which it is being subjected. Without an anesthetic, the patient screams and writhes in his agony; under an anesthetic, the respiration grows fainter and the heart beats slower; the latter manifestations, however, are really just as expressive as the former. The experience is without pain but the effects may be severe and are frequently fatal.

Dr. Crile's new operation method undertakes to overcome both causes of surgical shock the shock that comes from fear and the shock that results from physical injury. He calls this new method anociassociation new word meaning, as Dr. Crile defines it "the exclusion from the operation of all harmless association." In a recent article in the London Lancet, Dr. Crile describes very beautifully just what he is trying to do. He says:

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The principle of anoci-association may be illustrated by the wrecked Titanic. The story of the stress and the psychic strain of the survivors is known, that of the lost may be easily imagined; the future memory of this experience by the survivors may safely be predicted. Such is the result of the emotional surgical operation. Now, if a survivor of this ship had been so skilfully anesthetized in his bed just before the accident that he knew nothing of the impending disaster, and if he then had been gently carried up on the deck, lowered into a life-boat, and taken aboard the rescue ship without being allowed to awaken from his anesthesia until in bed in a comfortable stateroom if then he had been told that he had been transferred from the sinking ship, but that he was now safe and would soon see home, this would be anoci-association.

No one single anesthetic can accomplish these several results - remove the preliminary fear and overcome the brain exhaustion resulting from the wounding of tissue. By combining three or four different drugs, Dr. Crile has apparently attained complete success. Here,

for example, is the procedure adopted in abdominal operations. If possible, he keeps the patient ignorant of the fact that he is to undergo an operation at least of the time when the operation is to take place. As though for another purpose the surgeon gives him an injection of morphine. "Under the influence of morphine," says Dr. Crile, "no one is brave, no one is a coward; one is indifferent to danger." The drug simply produces a negative state of mind; the most awful sights and suggestions do not disturb the sick man in the least. The patient is simply in a philosophic state of cheerfulness and indifference and is ready for anything. The morphine thus protects him from the effects of psychical shock. He hasn't the slightest sense of discomfort or fear when the anesthetist now approaches with the once terrifying inhalation apparatus. Dr. Crile uses nitrous oxide in preference to ether, because experiments have proved that under this drug there is only one third as much shock as under ether. He relies upon another anesthetic method, however, to secure complete protection. Under the conventional anesthetic, as already said. the wounded tissues carry their messages to the brain by means of the nerves. These

nerves are just as active under ether as when we are our normal selves. A loca

anesthetic, however, produces insensibility to pain in the region affected, not by making us unconscious — under an application of cocaine we are completely awakebut because it interrupts the flow of sensation by means of the nerves. Under these conditions the tissues suffer like a besieged army. The enemy has captured them and is inflicting all kinds of injury and suffering. He has also cut the cables, so that the injured city cannot telegraph to headquarters the brain-for aid, that is, for a supply of stored-up energy In this case the patient suffers no pain, not even unconscious pain. The operation proceeds for any length of time. It usually is a success and the patient does not die.

In other words, Dr. Crile's experiments seem to have ushered in a new era of surgery - the era of the "shockless operation." At the Lakeside Hospital in Cleveland Dr. Crile has performed 2,672

operations with a death rate of less than 2 per cent. In the last 1,000 of these cases the death rate was less than 1 per cent.

Another improvement in operating conditions has saved many lives. This consists in the use of “laughing gas" and other anesthetics milder than chloroform or ether to produce the first stages of unconsciousness. This eliminates certain objectionable depressing effects upon the bodily temperature and upon the circulation of the blood caused by the more powerful agents. In the administration of ether, Dr. J. T. Gwathmey, of New York, has brought about two remarkable improvements; one, the warming of ether vapor to guard against bronchitis and excessive lowering of the body temperature; the other the combining of ether vapor with aromatic essences such as essence of orange — that rob the ether of its nauseating qualities and that do much to check the vomiting which usually follows its use.

Dr. R. H. M. Dawbarn, a distinguished surgeon of New York City, has attacked the problem of shock from another angle. He has perfected a method of reducing the loss of blood that is incident to most operations. Some authorities believe that the loss of a few extra ounces of blood may turn the scales of life and death against a patient who has been exposed to severe surgical shock. Dr. Dawbarn has adapted Dr. Dawbarn has adapted "Esmarch's bandage" to a novel and very useful purpose. Esmarch's bandage is an old device of a German surgeon to force the blood in the legs upward into the trunk when amputation is necessary. Dr. Dawbarn has carried this method to a more useful purpose by applying the bandage still higher on the body and so reversing its effect upon the circulation. By this By this method the blood is largely withdrawn from the arms and the trunk and is forced downward into the lower limbs, insuring a minimum loss of blood in operations upon the trunk. Contemporaneously with Dr. Dawbarn, Dr. Momburg, a German, applied the bandage to the waist, thus shutting off the blood supply below that level. Now all the body but the head and neck can thus be rendered bloodless.

Shock has been attacked from still another quarter by a number of other

surgeons, led by Dr. F. Pels-Leusden, professor of surgery in Griefswald University. For many years the deaths which result from severe burns were attributed to shock. Such burns are among the commonest accidents that befall workmen, and their treatment has been a grave problem with the medical profession. Women and children, too, because of the flimsy and inflammable character of their clothing, very often are victims of such burns. Longfellow's first wife was one of a long roll of women who have died in this way.

Dr. Pels-Leusden made some researches upon the theory that these burns produced other injurious effects in addition to the shock to the nervous system. His theory was that the sudden destruction of the skin generated a violent poison which was absorbed by the blood and this played a leading part in causing death. He tried experiments in which he inserted portions of freshly-burned skin into the flesh of animals where they would be rapidly absorbed. absorbed. These animals at once presented the symptoms that they would have shown if their own skin had been burned.

This discovery seems likely to revolutionize the surgical treatment of burns. Instead of merely applying germicides and excluding the air by soothing oils and powders, surgeons now place the patient at once under an anesthetic and scrape away all the burned tissue. The exposed surface is then dressed with absorbent cotton to take up the discharges, and the heart and kidneys are stimulated to throw off whatever poison has been absorbed before the operation could be performed.

Another radical alteration of theory has brought about possibilities in surgery that would have seemed fantastical only a few years ago. The theory concerns the cause of inflammation; the results are such startling operations as the successful restoration of a completely severed finger and such a perfectly feasible possibility as the transplantation of a finger or even certain organs, like the arteries and veins, from one person's body to another's. The old theory was that inflammation was caused by a "rush of blood" to the inflamed part, and surgeons treated it by blood-letting and cold packs to reduce the

supposed quantity and activity of the blood. But Professor A. Bier, of the University of Berlin, perhaps the foremost surgeon of Europe, held exactly the contrary theory. To his mind inflammation was an indication of stagnation. Naturally, therefore, the way to treat it was to stimulate the activity of the circulation. Another European surgeon, Dr. Jean Schaeffer, professor of diseases of the skin at the University of Breslau, originated the most practicable device for producing this stimulating effect. He applied intense heat, in the form of superheated dry air, to the surface above the inflammation. Astonishing results were achieved. culation was reestablished, and even tissues that before would have been described as dead beyond all human aid were restored to the normal function of life. This principle has made possible the operation to restore severed fingers, an operation that has now been successfully performed repeatedly.

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One of the most startling surgical innovations of recent years is a new method of removing tumors from the base of the brain. It has long been known that these tumors are a deadly menace. They press upon nerve centres that control some of the most important organs of the body and thus, for example, they often times cause blindness. More remarkable yet, they cause most extraordinary eccentricities in the structure of the entire body. This is because they usually originate in a small organ below the brain - known as the pituitary body. This structure, no larger than a pea, has some obscure but powerfully controlling effect upon the development of the body. If enlarged and active, it causes gigantism a state which only in recent years has been recognized as a disease. These tumors sometimes so disarrange the functions of this organ that its restraining effect upon growth is removed, and the patient continues to grow in stature and bulk beyond all normal proportions. For example, in a recent case in Philadelphia, a boy of fifteen had attained a height of 6 feet 7 inches and showed no signs of abating his extraordinary development.

Of course, an operation to remove such

a tumor is infinitely delicate. Dr. Harvey Cushing, another American, is practical the world's greatest operator in diseases of the pituitary body. Dr. S. Schloffer, of the University of Prague, originated the method of attack, that is as successful a it is bold. Instead of approaching the tumor from the side of the head, which is difficult and disfiguring, he entered directly through the front of the face. dividing the soft tissues and cartilages i the nose and, turning them back so they could be replaced without disfiguring scars. laid open a clear field for direct attack upon the bone which covers the tumor. The bone is easily removed and the tumor taken out. This striking operation is now freer performed, with satisfactory results.

America has perhaps furnished the great brain surgeons. Dr. Hartley, f New York, who died a few months a originated several technical advances that gave him world-wide fame, including the cure of neuralgia by removing the nerv organ within the skull which caused it. And Dr. Harvey Cushing is probab the foremost specialist in brain surge now living. Surgeons everywhere look: him for the newest advances in technic methods and for improvements in theor

Probably the most daring chapter modern surgery is that which treats 4 operations on the heart. "The road the heart is only two or three inches kr but it has taken surgery nearly 2.30 years to traverse it," is one writer's stri ing remark. How recent this work is made plain from the fact that a bo published by Stephen Paget in 1895, c tained a chapter on "Surgery of the Heat

the words being contemptuously closed in quotation marks. The scient as well as the layman, looked upon heart with an almost superstitious ast Any injury necessarily implied death; interference with such an injury could hasten the end. Yet many shrewd servers in the course of the ages had n ́t that all heart wounds did not result instantaneous death.

It was not until ten or fifteen years that surgeons began to act upon knowledge. In exceptional cases

did not result immediately from a ha