Extracts and Abstracts. On Some of the Limits of the Art of Surgery. Delivered at the Forty-Seventh Annual Meeting of the American (Concluded.) The art of surgery has its well-founded limits in the treatment of fractures of the skull. In my opinion, operative interference is absolutely indicated in fractures of the cranial vault under the following circumstances: 1. All open fractures, including gunshot and punctured fractures. 2. Depressed fractures attended by well defined symptoms caused either by the depression or intracranial complications. 3. Rupture of the middle meningeal artery with or without fracture of the skull. The use of the chisel or trephine is superfluous and often harmful in the treatment of subcutaneous fractures of the vault of the skull with or without depression, more especially in the case of children. The operation of trephining in the prevention of remote complications of fracture of the skull is often powerless, owing to the existence of visceral lesions which it can neither remove nor render harmless. The indiscriminate use of the chisel and the trephine in the hands of the inexperienced practitioner is fraught with danger and should not be encouraged by teachers and expert surgeons. Such teachings and practice are in conflict with the correct principles which should govern the true art of surgery. Brain surgery is of recent origin. It is in this department of the operative work of the surgeon that art has gone far in advance of the science of surgery. Cerebral localization and aseptic surgery have made it possible to treat a few intracranial lesions successfully by direct operative interference. Cerebral localization in its infancy and the minutest aseptic precautions do not absolutely protect against infection. A few years ago the columns of the medical press brought glowing accounts of the removal of brain tumors. Patients were exhibited at the meetings of different medical societies with enormous cranial defects and ghastly depressions marking the place from whence a large glioma had been removed successfully. Such cases aroused the most intense attention and interest at the time, but where are they now? Subsequent reports failed to appear, and an ominous silence remains regarding their ultimate fate. Many of the cases of tumor of the brain operated up on who never recovered from the immediate effects of the operation were never reported, and those who were fortunate enough to survive the fearful ordeal, after a longer or shorter interval joined the silent majority. One of the well defined limits of the art of surgery is the operative treatment of malignant tumors of the brain. Tapping and drainage of the lateral ventricles as taught and practiced by Dr. W. W. Keen may and undoubtedly will become in the future a useful and legitimate surgical resource in the treatment of inflammatory affections of that part of the brain, but so far it has not yielded encouraging results. When Lannelongue devised linear craniotomy for the liberation of the undeveloped, imprisoned brain in the skull of infantile idiots, his doctrine was received with open arms by many surgeons who occupy the front rank in the profession. The lay and medical press vied with each other in bringing before the general and medical public the wonderful results following the use of the trephine, chisel and rongeur forceps in opening the skulls of such unfortunate children. Many of these little innocents, of course, succumbed to the immediate effects of the operation, but this did not subdue the ardor of the surgeon, as he had been instrumental in transferring an object of pity to that happy home where microcephalus is unknown, and had relieved the family of a troublesome trust. Where are the cases that have been permanently benefited by the operation? Ask Lannelongue whether his hopes have been realized. I am free to confess that I have never been able to muster my courage to attack the skull of a poor, innocent and yet happy microcephic child, because I have always regarded the operation as useless in promoting brain development. The responsibility of the surgeon is not limited by the defective mental development of the child nor the importunity of the parents in demanding the operation at all hazards. The surgeon should stand guardian over such a charge, mindful of the limits of the art of surgery. Have we a right to estimate human happiness? The driveling idiot has many enjoyments and pleasures that you and I know nothing about. His responsibilities to God and man are limited, and his existence on earth is a long, happy dream, which only ceases when the soul leaves the imperfect body, and returns from whence it came, where mental distinction is unknown. The operative removal of inflammatory products from the cranial cavity and the brain has yielded the most satisfactory results, and constitutes one of the most important achievements of modern surgery. This part of cerebral surgery will reach perfection. with the progress of cerebral localization, and should be encouraged and cultivated by all who are desirous of extending the present limits of the art of surgery. Surgery of the Chest.-Modern surgery has done much toward the alleviation and cure of injuries and diseases of the organs of the chest, but it is here also that we are confronted by well defined limitations of the art of surgery. The successful treatment of hydrothorax and empyema of the pleural cavity is the result of a better knowledge of their etiology and pathology, and an improved operative technique under strict aseptic precautions. Tapping of the chest for tubercular hydrops, followed by iodoform glycerin injection has done more for this class of patients than counter irritation and the internal administration of digitalis, squills, acetate and iodide of potassium. Free incision of the empyemic pleural cavity after resection of one or more ribs, followed by efficient tubular drainage, has become an established practice by almost universal consent. The treatment of chronic empyema with thickened pleura and collapsed adherent lung by Estlander's multiple rib resection or Schede's thoracoplastic operation has yielded brilliant results. The treatment of abscess of the lung by rib resection, free incision with the knife point of the Paquelia cautery and tubular drainage, has been the means of saving many a precious life, which, without the aid of the surgeon, would have been doomed to a premature death. With few exceptions this is about all that has been accomplished by the surgery of the chest. It is true that a few surgeons have been fortunate enough to cope successfully with a few affections of the heart and its serious investment, the pericardium. Tapping of the pericardium for serious effusion has become one of the established operations in surgery. A very few cases of pyopericardium have been brought to a successful termination by free incision and drainage. We are familiar with isolated cases in which bold surgeons exposed the heart by a free incision for the removal of a foreign body, or sutured a visceral wound, and their effort was crowned by success, but, on the whole, we are painfully conscious of the fact that the art of surgery has done very little toward the successful treatment of injuries and diseases of this organ. Many have been the efforts of surgeons to supplant the physician in the treatment of pulmonary tuberculosis, the results of such efforts are familiar to you all. In the very nature of things, such trespassing upon the legitimate field of the physician has been fol lowed, without exception, by an ignominious failure. It is unfortunate, but true, that the surgical treatment of pulmonary tuberculosis by direct surgical intervention is beyond the legitimate limits of the art of surgery. Surgery has done very little during the last two decades toward a betterment of the treatment of penetrating stab and gunshot wounds of the chest. The careful surgeon knows that the hermetic sealing under aseptic precautions of the wound of entrance and exit, if such exists, affords the greatest degree of safety in arresting hemorrhage and in preventing septic complications. Free incision of the cavity of the chest with a view of arresting hemorrhage by ligature, or tamponade from any of the organs which it contains is attended by such great immediate risks to life that the possible benefits to be derived from it are more than overbalanced by the immediate dangers which attend such an aggressive course of treatment. The removal of malignant tumors of any of the organs of the chest is beyond the present limits of the art of surgery. Surgery of the Abdomen.-For reasons that we do not require an explanation here, the abdominal cavity was largely a terra incognita to the surgeon of less than half a century ago. To-day it is the favorite battle-ground of the average surgeon, and the select field of the so-called abdominal surgeon. The bold surgery of to-day upon the organs of the abdominal cavity is largely due to the comparative safety with which the peritoneal cavity can be invaded under proper aseptic precautions. This new field for the display of surgical talent and ingenuity has been diligently cultivated in a legitimate way by the honest progressive surgeon, but it has also been made the playground of unscientific sensational surgery by men who are ignorant of the legitimate limits of the art of surgery. The simple fact that any of the abdominal organs, in part or in whole, can be removed successfully without much danger to life does not establish the legitimacy of the surgical procedure. Billroth, one of the greatest and certainly one of the most honest surgeons of this age, did not realize the expectations he entertained in regard to the benefits to be derived from direct surgical intervention in cases of carcinoma of the stomach, justifying surgical interference. Notwithstanding the wonderful improvements in the technique of operations upon the stomach, partial gastrectomy and pylorectomy have yielded anything but encouraging results. In nearly 50 per cent. the patients subjected to radical treatment for malignant disease of the stomach succumbed to the immediate effects of the operation. In all of the cases which survived the operative ordeal, the patients succumbed to a relapse in from a few months to several years. I have opened the abdominal cavity for the surgical treatment of malignant disease of the stomach, nineteen times, and only in one case did I find the disease limited to the organ primarily affected, and in this case 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. 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 Much 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 |