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the general health of the patient had been so much deteriorated by the obstructive pyloric carcinoma as to contraindicate a radical operation, in all of the remaining patients a pylorectomy or partial gastrectomy was out of the question, as the carcinoma of the pylorus or stomach had extended to adjacent organs or had given rise to regional infection through the lymphatic glands sufficiently to contraindicate any attempt at radical removal of the disease. The legitimate limits of the art of surgery in the treatment of malignant disease of the stomach embrace the cases in which a sufficiently early diagnosis can be made when the malignant disease is limited to the organ primarily involved and the strength of the patient is adequate to overcome the immediate effects of the operation. The removal of the carcinomatous pylorus or any part of the stomach after the malignant disease has extended to adjacent organs or after regional infection through the lymphatic glands and channels has taken place is tampering with the present limits of the art of surgery. The palliative operations for carcinoma of the cardiac and pyloric extremities of the stomach have yielded excellent results, and should receive the sanction of every surgeon who has the best interests of his patient at heart. Witzel's operation for establishing an external gastric fistula in cases of malignant obstructive tumors at the cardiac orifice of the stomach, and Rockwitz-Wölfler's operation for pyloric carcinoma are the palliative operations which promise the most with the least immediate risks to life in all cases of malignant tumors of the stomach which give rise to obstruction. The treatment of intestinal obstruction by surgical intervention has become an established custom. Physicians and surgeons imbued with a proper moral and scientific sense, recognize the importance of early surgical interference in all cases of intestinal obstruction, due to mechanical causes. An early positive diagnosis is an essential prerequisite to success in such cases which must be followed by prompt action on the part of the surgeon. Intestinal surgery will celebrate its greatest triumphs with the progressive development of our diagnostic resources in the early recognition of the nature and location of the mechanical causes which give rise to intestinal obstruction. Volvulus and invagination, some of the most serious forms of mechanical obstruction, if they could be recognized within a few hours of their appearance and subjected to surgical treatment at once would no longer figure so conspicuously in our mortality reports. The division or excision of a constricting band in the treatment of intestinal obstruction from such a source, if performed in time, would yield a very small mortality, but if not brought within the present
limits of the art of surgery, such cases seldom recover from the immediate effects of the operation.
The radical treatment of malignant tumors of the intestinal canal has not been attended by satisfactory results as a rule. In the majority of cases the operations were postponed until the malignant disease give rise to symptoms of obstruction, when it was usually found that the carcinoma had passed beyond the legitimate limits of a radical operation. The implication of adjacent organs and extension to the lymphatic glands of the mesentery must be recognized at the present time as positive contraindications to a radical operation. With few exceptions the transgression of this rule in cases in which the patients survived the immediate effects of the operation was followed by an early recurrence of the disease to which the patient rapidly succumbed. Palliative operations in cases of malignant obstruction of the intestinal canal above the rectum, by establishing an anastomotic opening between the intestines above and below the obstruction, have become recognized procedures in surgery. In establishing such a communicating opening, the employment of mechanical devices, such as the metallic buttons of Murphy, Ramaugé and Chaput, which must pass the intestinal canal unchanged, is a procedure fraught with more or less danger, which is being recognized more as the experience with them increases. In my own practice I have largely dispensed with the perforated decalcified bone-plates, and now rely more frequently on the needle and thread in performing such operations, and the mass of the profession is in accord with this practice. The custom followed by many American surgeons to remove the appendix in all cases in which a diagnosis of appendicitis is made, is a very harmful one. The removal of the appendix should be limited to those cases in which, during the first attack symptoms arise which portend danger to life and relapsing appendicitis. Some cases of appendicitis yield to medical treatment, and in a large percentage of such cases the patient remains free from a second attack. Pancreatic surgery at the present time is limited to the treatment of cysts by establishing and maintaing an abdominal fistula until the cysts become obliterated. The extirpation of pancreatic cysts and partial pancreatectomy for malignant disease are operations fraught with danger, and do not come within the legitimate limits of the art of surgery at the present time. Much has been done of late in the way of developing and enlarging the sphere of the surgery of the liver and biliary tracts. Recent clinical experience and the results of experimental research have shown that a considerable portion of the liver can be removed for injury or
disease with a fair expectation of success. The treatment of gunshot and stab wounds of the liver by laparotomy and suturing or tamponing of the visceral wound has yielded encouraging results. A number of successful cases of excision of isolated adenomatous tumors of the liver have enriched and graced our modern surgical literature. The operative removal of malignant tumors of the liver is an undertaking far beyond the present limits of the art of surgery. The successful treatment of abscess of the liver and echinococcus cysts by direct surgical intervention is generally recognized as one of the greatest achievements of abdominal surgery. The pioneer work of Sims and Kocher in laying the foundation for a rational treatment of impacted gallstones in any part of the biliary tract has yielded unexpected results, and has been the means of saving thousands of lives by averting the dangers from perforation and cholemia by a timely surgical intervention. The removal of calculi from the gall bladder can now be accomplished with very little danger to life. The cystic and common duct the seat of an impacted calculus are now exposed and incised, the calculus extracted and the wound sutured or drained, with a well-founded hope that the patient will recover, and that the operation will result in restoring the free flow of bile through the biliary passages. I have reason to believe, however, that the surgery of the biliary passages has been carried too far. That unnecessary operations have been performed upon the gall bladder and the biliary ducts, no one will deny. The simple fact that the patient is suffering from gallstones does not furnish a positive indication for surgical interference. The physician and nature's resources should be given a chance, and the surgeon's services should be limited to those cases in which positive indications for operative treatment present themselves. The surgeon who recorded the first successful case of cholecystotomy has since become the victim. of gallstones, but instead of calling upon one of his colleagues to open the gall bladder and. remove the stones, he made a pilgrimage to Carlsbad and was promptly relieved of his sufferings. Cholecystenterostomy should only be performed in cases in which the common bile duct is permanently occluded by an impacted irremovable gallstone or cicatricial stenosis. Catheterization of the cystic and common bile ducts preceded or followed by dilatation by the use of laminaria tents in the treatment of impacted stones and cicatricial stenosis after the formation of a gall bladder fistula is a much neglected part of the surgery of the biliary passages and of sufficient importance to invite new trials and investigations. For substantial reasons abdominal nephrectomy and nephrotomy have been sup
planted by lumbar operations. The treatment of tubercular hydrops of the peritoneum by incision, drainage and iodoformization remains in favor with the profession, and continues to yield the most satisfactory results.
Organs of Generation.--The greatest onslaught of modern surgery has been upon the organs of generation, male and female. It is somewhat strange that the organs created for distinguishing the sex and for the increase of the human species should have been singled out as innocent objects of so-called modern aggressive surgery. The future historians who will record the work of many gynecologists belonging to the present generation will have reason to express their surprise at what disasters the art of surgery has produced when plied in cases far in advance of a scientific foundation. Here and there we hear a feeble voice protesting against the indiscriminate surgery upon the organs of generation of the opposite sex, but the mutilating work continues in spite of such opposition and wellmeant advice. Every competent and honest gynecologist knows that in his sphere the art of surgery has been thoroughly abused. It is difficult to assign tangible reasons for such a fearful state of things. It appears to belong to the spirit of the present generation, the outcome of ceaseless unrest in pelvic surgery. When I arraign the gynecologists before this body composed of representative medical men of this country for innumerable and inexcusable transgressions of the rules which ought to govern and control the art of surgery, I do not include the scientific, honest, conscientious workers in that department of surgery, but my remarks will apply to a class of routine operators which has recently grown to alarming dimensions not only in this but in nearly every country which has been penetrated by the dim rays of so-called bold surgery. It is a subject that I would gladly pass over in silence, but. you have imposed upon me a trust which I cannot ignore and I stand here in the capacity of the conservative element in these days of wild, unfounded surgery to place myself on record in protesting against the unnecessary mutilation of the sexual organs of either sex, willing to stand or fall by the sentiments of the great mass of general practitioners, which after all, must be regarded as the backbone and final tribunal of our profession. The new generation of doctors finds no longer satisfaction in practicing their profession in some rural district. The young practitioners have their eyes on large cities and have heard of enticing fees paid to specialists for insignificant operations. Why buy a horse and saddlebags when a fortune awaits them in devoting themselves to a specialty, more particularly gynecology? The recent graduate or the man who has become
disgusted with country practice seeks a much employed gynecologist, follows his work for a month or two and returns to his prospective field of labor a full-fledged specialist. He is now ready to extirpate the uterus, remove ovaries and Fallopian tubes, sew imaginary lacerations of the cervix and perineum. Do you suppose that such an aspirant for gynecologic fame ever examines a woman and finds her perfect? Is it not true that in nine out of ten cases he finds something to mend? That my views are real and not visionary, let me relate a few instances. A number of years ago a young lady accompanied by her grandmother applied to me for treatment for a neurasthenic affection. I was informed by the grandmother that a few days before they had consulted a young gynecologist, who made a hasty vaginal examination, looked wise and informed them that he had found the source of all trouble in the form of a laceration of the cervix, which would require an operation. As a matter of course the grandmother asked for an explanation of the injury and was promptly informed that it was one of the common accidents of childbirth. As the patient was unmarried and had never been pregnant this explanation proved unsatisfactory to the interested parties and no arrangements were made for the prospective trachelorrhaphy-upon a virgin uterus. Not long ago an unmarried woman came under my care who had been told by an ambitious gynecologist that she was suffering from a myoma of the uterus which would necessitate a vaginal hysterectomy. I found a sharp anteflexion, the anterior wall of the uterus being prominent and somewhat edematous had been mistaken for a tumor and nothing short of a hysterectomy would satisfy the operator. This patient recovered under conservative treatment without the loss of an important organ. The cases which I have just cited escaped mutilating operations by doubting the diagnosis of those to whom they first applied for treatment; others are less fortunate. Suffering women will believe in and submit to almost everything. In fact it has become almost a fashion for a woman suffering from real or imaginary affections of the genital organs to consult a gynecologist as regularly as her dentist or dressmaker. Not long ago a girl of 18 years of age was brought to me with the information that she became epileptic when 7 years of age, that later, when menstruation was established, the attacks never occurred during the menstrual period, and yet both of her ovaries were removed by a gynecologist. As could be expected, the epilepsy remained and when I saw her she was on the verge of insanity. Time does not permit to cite additional illustrations showing criminal trespass upon the legitimate limits of the art
of surgery in the treatment of real or imaginary ailment of the female organs of generation. Every practitioner has seen such instances as I have cited above. Has humanity been the gainer since the gynecologists became surgeons? This is a timely and serious question. Is the average woman who has passed through the hands of one or more gynecologists physically and mentally in a better condition than our mothers of fifty years ago whose ovaries were safe and who knew but little about speculums and vaginal douches? Let the older members of our association answer this question. When the venerable and distinguished Emmet devised this operation for laceration of the cervix he pointed out clearly what conditions called for and were benefited by trachelorrhaphy. The operation was received with enthusiasm and everyone present here knows how much it has been misapplied. It is safe to assert that not one in ten cases that have been operated upon was the operation justifiable or proved of any benefit to the patient. Emmet's teachings and practice were in consonance with sound pathologic principles, but hundreds of imitators were less discriminating in the selection of cases, and performed the operation simply because they found a laceration of the cervix, irrespective of the existence of symptoms which could be referred to this condition. Laceration of the perineum is another favorite subject of the "amateur" gynecologist. The extent of laceration and the symptoms caused by it are not always taken into careful consideration in deciding upon the propriety of an operation. To "do a perineum" in five to seven minutes still serves as an attraction for the lookers-on in many private hospitals and gynecological clinics. I fully appreciate the value of a well-performed perineorrhaphy in proper cases, but I am equally well satisfied that the operation has often been performed unnecessarily, and that it requires more than five or seven minutes to perform it properly. The late lamented Robert Battey opened a wide field for operative gynecology. This modest, honest worker conceived the idea that the removal of the normal ovaries would become a useful surgical resource in the treatment of certain nervous affections which before had baffled the skill of physicians. It required some time and the additional support of Hegar and Tait for his views to become popular among his colleagues. Battey lived long enough to learn that his example and teachings have created a wave in the misapplication of the art of surgery which to-day remains mountain high, and it is difficult to tell where it will end or where a rock sufficiently high and strong will be found to break its force. The frequency with which women are being castrated to-day is one of the most
flagrant transgressions of the limits of the art of surgery. It is not unusual for one operator to exhibit from five to six normal ovaries as the result of half a day's work. All kinds of excuses are made for this kind of surgery. The ovaries are too large, cirrhotic, cystic, or perchance a ruptured Graafiian follicle is discovered, when he consoles himself that he has removed an apoplectic ovary. Where is this wholesale unsexing of our female population going to end? The beginning of the end has come. The army of women minus their essential organs of generation is beginning to raise its voice against such mutilating work. The number of women who willingly sacrifice their ovaries to restore their shattered health without securing the expected relief has increased to an alarming extent. This sad experience has made the gynecologists more desperate and bold. They have been importuned by their castrated, tubeless patients to such an extent that the art of surgery was again resorted to. The uterus, which heretofore had been comparatively safe, was now selected as the offending body, and vaginal hysterectomy became at once a popular operation. Many atrophic uteri remaining after removal of their appendages have been removed in a vain hope of securing permanent relief. Vaginal hysterectomy for diseases other than carcinoma is now at its height. The uterus is being removed for hypertrophy, endometritis, flexion, version and minute myofibromata. This important organ is no longer safe if it is in the vicinity of a pelvic abscess. Perchance a healthy uterus is removed under the pretense of securing a more direct route to a focus or foci of pelvic inflammation. It is needless to say that most of the surgeons who clamor for the removal of the uterus through the vagina for insignificant affections or inflammatory lesions of adjacent parts, do so by the use of compression forceps. It is no great surgical feat to squeeze out an inflamed or displaced uterus between compression forceps. It is difficult to say where this rage for the removal of the female sexual organs will end or what organ will be the next battle ground for the aggressive gynecologist. The clitoris, the vagina, the cervix uteri, the ovaries, the Fallopian tubes, the uterus and its ligaments have successively passed through a trying ordeal of the furor operativus. What the next fad will be is impossible to foretell. As one operation after another is falling into a well-deserved desuetude new ones will have to be devised to gratify the whims of the patients and the ambitions of the gynecologist. I have portrayed to you only a few of the excesses of the art of surgery as applied to the female organs of generation, but enough has been said to show you that it is time to call a halt. Further depredations can best be
avoided by the general practitioners to whom most of the patients apply for relief. Let them do their duty toward their patients. Many of the minor affections of the uterus and its appendages are within the reach of intelligent general and local treatment without a recourse to the knife. If gynecology is to live and become a real benefit to women suffering from pelvic disease, it must become more conservative. We all appreciate what surgery has done in prolonging life and in mitigating suffering in the treatment of ovarian cysts and the removal of the uterus, the seat of symptom-producing myofibromata. What I am objecting to, and on good ground, is the indiscriminate operating upon the female organs of generation for imaginary or insignificant affections. This is an evil that must be apparent to all and that the leaders of gynecology must assist us to suppress.
I cannot dismiss the subject of genital surgery without making a strong plea in favor of conservatism in the treatment of prostatic hypertrophy. A few years ago J. W. White made a series of experiments on dogs which proved that the testicles possessed an influence which, to a certain degree, controlled the nutrition of the prostate gland. His experiments were made on dogs, the animals being vigorous and in full possession of their sexual power. He found that castration was constantly followed by progressive atrophy of the prostate gland. At that time he timidly suggested that castration in cases of prostatic hypertrophy might possibly prove to be a valuable surgical resource in the treatment of uniary obstruction due to such a cause. About the same time Ramm gave the result of his clinical experience, covering about the same ground, urging the utility of castration as a legitimate surgical procedure in the treatment of non-malignant obstructive enlargement of the prostate, a condition so frequently met with in men advanced in years. You are familiar with the subsequent history of this operation. Numerous operations have been performed in different countries which appear to support the claims made for it by both of these investigators. The operation has been modified in substituting for the castration section or resection of the vas deferens, and recently neurectomy of the spermatic nerves; both of these procedures are said to produce the same curative effect as castration. A sufficient clinical material has accumulated to prove that these different procedures frequently result in diminution in the size of the prostate and that the symptoms caused by the obstruction often diminish or disappear.
I can readily understand in what manner emasculation in young animals and young and middle-aged men should be followed by atrophy of the healthy prostate gland.
tration of women during active sexual life will bring about atrophy of the uterus as a constant result. Clinical experience has also shown that the anticipated menopause effected by castration has a decided effect on the myomatous uterus. But who would think of castrating a woman who has reached the menopause for such an indication? It is very difficult to understand how castration or its substitutes performed on men advanced in years, with atrophic dormant testicles should exert such a positive influence upon an organ, the seat of senile affection And yet, the fact remains that many reliable men have observed such results, and we can no longer doubt them
What I fear, and the reason I allude to this subject, is this, that castration of aged men for hypertrophy of the prostate, when this operation becomes common property and is endorsed by surgeons who stand high in the estimation of the profession, will be misapplied in the same way, fortunately, probably to a lesser extent than the removal of normal ovaries. Men will be castrated for stone in the bladder, chronic cystitis and malignant disease of the bladder. It is not always easy nor possible to make a positive differential diagnosis between simple hypertrophy of the prostate and some of the conditions which simulate so closely. In doubtful cases it appears to me it would certainly be advisable to make the diagnosis sure by a supra-pubic cystotomy before resorting to a mutilating operation, rather than remove the testicles and later discover a tubercular bladder or encysted stone or malignant disease of the bladder or prostate. Castration is such an easy operation that every tyro in surgery will be tempted to perform it upon willing subjects suffering from obscure affections of the bladder, complicating hypertrophy of the prostate gland. The RammWhite operation deserves a fair trial at the hands of competent surgeons, in well-selected cases, but I apprehend evil in the future, not so much from the proper use as the abuse of this procedure. In short, it is probable that this new surgical resource, which has not yet passed the trial stage of a legitimate established surgical procedure, will on a smaller scale become a repetition of the unenviable history of castration of the opposite sex. We have every reason to believe that so far the apparently successful cases have found their way into current medical literature, while the cases in which the operation has proved a failure, with few exceptions, have for apparent reasons not been published.
⚫ Gentlemen: It has been my purpose to call your attention in the brief time allotted to the delivery of this address to some of the limits of the art of surgery and to a few of the most flagrant prevalent trespasses of its legitimate
limits by undiscriminating surgeons. I wish time would permit me to say something of the too frequent recourse to the recently revived operation of symphyseotomy and the unwarranted procedure known as Porro's operation, except in cases in which the uterus is the seat of a life-threatening affection, some of the evil results following the too frequent performance of ventro-fixation of the retroverted uterus, and many other topics in general surgery and gynecology to which no allusion has been made, where the limits of the art of surgery have been ignored, and too often reckless operating has disgraced the fair fame and reputation of our noble profession. Let us have in the future more of the nil nocere in place of the furor operativus. I have written and delivered this address with malice toward none, in the interest of the suffering portion of our population, for the true advancement of the science and art of surgery, and as a plea for recognition of the good work done by the great mass and backbone of our profession, the modest, toiling, inadequately remunerated general practitioner. Journal of American Medical Association.
(429) Changes in the Spinal Cord After Amputation of Extremities.
Grigoriew (Zeit. f. Heilk., vol. xv, p. 75) investigated 2 cases of amputation of the arm, 2 of amputation of the thigh, and I of amputation of the leg. The period elapsing between operation and death varied from twenty years. to I year. The results of his investigations agree with those of the greater number of authorities, and are collected by the author in the following summary: In all cases excepting that in which one year elapsed before death, deviations from the normal appearance of the cord were noticed; in all cases they were analogous, affected the corresponding portions of the cord, and consisted in a simple atrophy of certain portions of the grey and white substance differing in the cases only by the degree of development. The simple atrophy of the nervous elements of the cord was greater as the period elapsing between amputation and death was greater, less as it was less; while in the case in which the period was only one year, atrophy was completely wanting. With reference to the relative time before the separate paths and portions of the cord became degenerated, the author found his cases in agreement with those of other authors, and with those obtained by experiment on animals, namely, that the atrophic phenomena appear earlier and are more marked in the sensory than the motor areas of the cord.-British Medical Journal.