Robert Tuttle Morris - The Fourth Era in Surgery

The Fourth Era in Surgery

Robert Morris makes a distinction in his autobiographical book of his idea of the existence of four distinct eras in surgery, one by one characterized by a certain aspect. So he talks about a Heroic Era, then an Anatomic Era, a Pathologic Era and finally a Physiologic Era.

The first one is about all that happened before doctors concentrated their studies upon Anatomy. So it lasts from the time of Hippocrates since the introduction of a rigorous study of the structure of human body. Since then operations were made with brutal rapidity, and there was no regard for antisepsis.

The second era is signed by progress in knowledge and skills, but still surgeons would make unnecessary long incisions for their operations, ignoring the damage they could procure by using this method, making after all the body of the patient in front of a higher risk to get infected.

Then with Lister and Pasteur discoveries there it came the third era, characterized by the consciousness that the microbe had to be consider bigger than the man (In the First and Second Eras of surgery man was bigger than the microbe; in the Third Era the microbe was bigger than the man). But still, using Morris' own words, incisions suitable for killing bears were being applied to weak patients and also surgeons made multiple incisions for purpose of drainage and these also caused shock.

The last one era is based upon the revolutionary and recent idea that the patient, on the whole, is his own best antiseptic. He was a pro of this new point of view, which was contrasted for a long time, since it had come universally accepted. Inspired by an experiment made by Dawbarn (who was able to demonstrate that the pus originated in an abdominal infection could not be all removed in the course of the surgical operation by making a sort of try by pouring milk into the abdominal cavity of a cadaver and then trying in vane to get it completely out), he started to operate appendicitis with a new revolutionary method based upon the reduction of shock for the patient, making small incisions, and omitting pads (used for the purpose of protection) and the excessive drainage.

So he made a number of operations of the appendicitis using his own method, and then he was able to present in 1896 at the Academy of Medicine statistics of one hundred consecutive unselected appendicitis cases with a death rate of 2 per cent. His first formal presentation of these principles of the Fourth Era of Surgery (as he named it) was made before the Section of Surgery and Anatomy of A. M. A. and reported in the Transaction of the year. He also presented it at the International Medical Congress in Budapest in September 1909, and published his idea in Surgery, Gynecology and Obstetric for December. And he also published a book, Dawn of the Fourth Era in Surgery in 1910.

Anyway his results were not completely appreciated by other surgeons, for the appendicitis cases had at that time a high death rate. Some surgeons affirmed that those statistics were not to be taken seriously, since what they proved was impossible. He still improved his methods and skills and he furnished a contribution on Abdominal Surgery for Sajous' Cyclopedia.