THE CONSERVATIVE 
TREND. 
BY 
JABEZ N. JACKSON, A. M., M. D., 
Professor of Anatomy and Adjunct Professor of Surgery, 
University Medical College, Kansas City, Mo. 
REPRINTED PROM THE 
Neto Yotfe jj&etttcal Journal 
for August 1, 1896. Reprinted from the New York Medical Journal 
for August 1, 1896. 
TIIE CONSERVATIVE TREND.* 
By JABEZ N. JACKSON, A. M., M. D., 
PROFESSOR OF ANATOMY AND ADJUNCT PROFESSOR OF SURGERY-, 
UNIVERSITY MEDICAL COLLEGE, KANSAS CITY, MO. 
A ckitical review of the progress of surgery during 
the past year impresses one with the fact that it has been 
a period not so much of innovation and discovery, but 
rather one of deliberation and development. The work 
of the past decade in surgery has been both voluminous 
and brilliant. The dawning of the new era of antisepsis 
and asepsis has been followed by most startling achieve- 
ments. The danger of sepsis and its correlating condi- 
tions, which ere this time rose as a black nightmare be- 
fore the vision of Ambition, had limited surgery to a 
comparatively narrow part of the great science of heal- 
ing. Before the immortal discoveries of the great Sir 
Joseph Lister, however, in one moment the forbidding 
walls were laid low. Fields of investigation hitherto 
looked upon only as terra incognita now became the 
scene of busy activity in surgery. Pathological condi- 
tions which had previously baffled the wisest counsel 
* Address as Chairman of the Committee on Progress of Surgery of 
the Missouri State Medical Association, at Sedalia, Mo., May 20, 1896. 
Copyright, 1896, by D. Appleton and Company. 2 
TIIE CONSERVATIVE TREND. 
and most ingenious devising of medicine now invited 
the efforts of the new surgery. Enthusiasm naturally 
ran wild, and with neither chart to guide nor theory to 
control, experimental surgery began its new career. Be- 
fore each aspiring surgeon lay open rich fields of unex- 
plored wealth, with visions of fortune and eternal fame 
awaiting his command. Each man a pioneer and none a 
guide was truly an enticing opportunity. The work of 
the past decade has naturally, therefore, been more 
fraught with discovery than that of any which had gone 
before—nay, perhaps, than that of all which had gone 
before—and gives it rank in history as the golden age of 
surgery. Many of its achievements have brought ines- 
timable good to the human race, and paved the way for 
surgery to its recognition as one of the grandest and 
noblest of all the sciences and arts. 
It is not my purpose in this paper to detract in the 
least degree from the high measure of praise and com- 
mendation due to the surgery and to the surgeons of the 
decade that is gone. As, however, the explorer of all 
new lands, unguided by experience, commits errors ap- 
parent to his retrospection, so surgery in its new work 
has with enthusiasm advanced some doctrines which its 
present wisdom and experience must lead it to discard. 
The collection of data must precede the classification 
and establishment of any true science or the enuncia- 
tion of fixed principles arising therefrom. These years 
which have gone before, therefore, have been invaluable 
in the collection of vast elements of advanced truth. 
The past year, though indeed largely barren in new 
exploration, must likewise be considered as time most 
wisely spent in the critical analysis of the facts already 
adduced and in the deduction of sound principles for THE CONSERVATIVE TREND. 
3 
future work. This is the time of reckoning, and we 
should now be able to in a measure weigh our discover- 
ies and ascertain the true relation of surgery to the prob- 
lems of human life and human happiness. The result of 
these deliberations has demonstrated to us many excesses 
of our zeal and led to a decided trend toward conserva- 
tism in surgery; not that conservatism, however, which 
but masks the face of ignorant inactivity, but a truer 
and higher conservatism which puts life first, then func- 
tion, and finally form. 
In the limited confines of this paper it would be 
manifestly impossible for me to indicate the scope of this 
conservatism in all the departments of surgery. I shall 
therefore confine my remarks to some of its applications 
in various affections of the great cavities, since it is in 
this realm that radicalism has been most marked and has 
done the greatest damage as well as the greatest good. 
Brain Surgery. 
We are to-day just emerging from an inundating 
tidal wave of brain surgery. Within the past few years 
there has been scarcely a pathological condition to which 
the brain is subject that has not been submitted to the 
trial of operative surgery for its relief. Medical skill 
had for years exercised its best efforts for the cure or 
control of diseases of cerebral origin, and, in a vast ma- 
jority of conditions, with but limited or no success. 
With great expectation and hope, therefore, the profes- 
sion turned its thoughts to the possibility of relief by 
surgical measures. In this department of work has been 
enlisted the services and talents of many of the most 
distinguished members of the brilliant mass of modem 
surgeons, aided and counseled by the most eminent neu- 4 
THE CONSERVATIVE TREND. 
rologists throughout the world. True it is these labors 
have brought to us knowledge of inestimable value. 
Cerebral localization and an accurate understanding of 
much of the physiology and physiological anatomy of the 
various portions of the brain are achievements which 
have placed medicine upon a scientific and accurate basis 
in the diagnosis of cerebral pathology, and shall forever 
stand as a brilliant record to the credit of brain surgery. 
But how disappointing, alas, have been all our efforts 
when viewed from the standpoint of therapeutic value! 
Epilepsy.—The possibility of relieving the distress- 
ing and heretofore largely hopeless cases of epilepsy, for 
instance, how eagerly and even enthusiastically it was 
embraced! The theory that all epilepsy of cerebral ori- 
gin was attributable to local excitation, and that the re- 
moval of the offending cause would insure a disappear- 
ance of its ensuing clinical manifestations, seemed indeed 
logical, both in its premises and in its conclusions. All 
forms and degrees of epilepsy, whether general or focal, 
have been, therefore, subjected to varied operative pro- 
cedures. The temporary benefit following nearly all 
operations for a short time led us at first to believe that 
we finally had found the happy solution of this vexatious 
problem. How limited, alas, have the ultimate results 
moved our power! In general epilepsy it was soon dem- 
mstrated that nothing is to be expected from surgical 
intervention. This, however, has occasioned no great 
surprise, as little rational hope was ever entertained 
for this class of cases. Even in focal, cortical epilepsy, 
however, dependent upon a distinct and localized lesion 
susceptible of removal, the history of our work shows 
a sad lack of permanency in results. As Eulenburg says: 
“ By the excision of an area of the cerebral cortex the THE CONSERVATIVE TREND. 
attacks may be made to stop for a short time; but they 
return after a while.” Yon Bergmann further asserts, 
that “ only those cases of cortical epilepsy are cured by 
trephining which are due to tumors, especially cysts, 
which are often the results of intrameningeal exuda- 
tions due to traumatism over or within the circumscribed 
motor area.” Nancrede also affirms that his experience, 
like that of Horsley, Keen, and other surgeons, has 
demonstrated a lack of permanency in results, and looks 
upon the removal of the discharging lesion in cortical 
or Jacksonian epilepsy as a merely palliative procedure. 
He further observes that “ the earlier the operation is 
done after disease has become established, the longer the 
immunity,” and adds that “ it is possible that if trephin- 
ing were resorted to early, the operation in a few in- 
stances might prove curative, if a reliable method were 
devised to prevent the inevitable scar, and the adhesions 
between the brain and its meninges.” Universal ex- 
perience, however, demonstrates that after degeneration 
of nerve substance has set in, it is too late for surgery. 
We may remove the primary cause; but the degen- 
eration, which is the secondary and efficient cause of epi- 
lepsy, is beyond our control with present methods. One 
vastly important observation, however, has been im- 
pressed upon the surgeon’s mind by his experience in the 
surgery of epilepsy—namely, that a large percentage of 
the cases of epilepsy are due to remote traumatism of 
the skull, either unrecognized at the time or, if recog- 
nized, improperly handled. The significance of this ob- 
servation should not be overlooked in dealing with any 
injury about the head, and I confidently believe that 
the true conservative surgery of traumatic epilepsy is 
the radical surgery of the trauma. With Lanphear I can 6 
THE CONSERVATIVE TREND. 
quite agree in the aphorism that “ the way to cure trau- 
matic epilepsy is to prevent it.” 
Imbecility and Idiocy.—The operative treatment 
of imbecility and idiocy has also proved a complete fail- 
ure. As Dana has aptly said: “ This operation was origi- 
nally devised on the theory that by cutting open the 
skull of the microcephalic child, opportunity was given 
the brain to grow. This theory, which was never sub- 
stantiated by facts and never held by any experienced 
neurologist, has been, of course, overthrown. . . . What 
the operation does is this: It has a profoundly disciplinary 
effect upon the idiot. . . . The operation of craniotomy 
upon children in institutions attracts the attention of 
nurses and of all the medical officers, and the children get 
more care and more stimulating words of help in various 
directions. I would repeat, therefore, that it is in my 
opinion largely due to its pedagogic influence that an 
improvement in these cases takes place, and that the 
operation is allied in its effects to a severe piece of casti- 
gation.” Many surgeons have, however, justified and 
praised this character of work on the ground that, in 
view of the absolutely hopeless and practically helpless 
condition of these unfortunates, their lives were but a 
burden to their friends and a mere blank to them- 
selves. 
The moral side of the question has been apparently 
lost from view in our excessively utilitarian tendency. 
In his masterly address on surgery before the recent 
meeting of the American Medical Association, Senn very 
beautifully and forcibly draws attention to this subject 
in the following language: “ I am free to confess that 
I have never been able to muster my courage to attack 
the skull of a poor microcephalic child, because I have THE CONSERVATIVE TREND. 
7 
always regarded the operation as useless in promoting 
brain development. The responsibility of the surgeon 
is not limited to the defective mental development of the 
child nor the importunity of the parents in demanding 
an 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 hap- 
piness? The driveling idiot has many enjoyments 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.” 
Abdominal and Pelvic Surgery. 
In abdominal surgery, perhaps, the most brilliant ad- 
vances in operative work have been recorded. The sur- 
gery of this cavity has been simply marvelous when we 
consider the short time in which it has all been accom- 
plished. The invasion of the abdomen prior to the 
enunciation of the principles of antisepsis was a venture 
hazarded only under conditions of most exacting neces- 
sity, and then with fear and trembling by even the bold- 
est of surgeons. How marvelous the change, when now 
the operation is of almost daily occurrence in the practice 
of surgeons of eminence, and by many declared a safe 
and wise procedure even for exploration and diagnosis! 
Has not our enthusiasm here also carried us beyond the 
limits of scientific rationalism, and made surgery in many 
instances more a matter of mechanical dexterity than of 
mature judgment and wisdom? 
The present trend of surgical opinion certainly ap- 
preciates this as a fact. While the conscientious surgeon 8 
THE CONSERVATIVE TREND. 
should not now hesitate to open the abdomen under 
any circumstances of accurate indication, yet he must, 
if he be true to the teachings of experience and honest in 
his relations to his reliant patient, remember that the 
opening of the abdominal cavity is not absolutely free 
from much danger even in simple cases in the hands 
of trained operators, and under strictest precautions, 
the old axiom, “ Be sure you are right and then go 
ahead,” is worthy the memory of the scientific surgeon 
even to-day. Let us he thankful that the brain is once 
more to be recognized in surgery and not the hand alone. 
Appendicitis.—From the many operations within 
the abdominal cavity I have singled out appendicectomy 
for a brief consideration; not because it is more impor- 
tant than many others, hut because herein radical sur- 
gery has gone to its absolute extremes and been thor- 
oughly tested and discussed. Just what is the proper 
relation of surgery to the inflammatory affections of the 
appendix is, in my judgment, still an open question. 
The insidiousness of the disease, its manifold aspects 
clinically, the uncertainty of the differentiation of its 
various forms, and the impossibility of foretelling its 
course, render a scientific and fixed stand impossible in 
the light of our present knowledge. Unfortunately, the 
mass of clinical observation in appendicitis scientifically 
recorded has been from cases surgically treated. This 
aspect of the disease has therefore been carefully weighed. 
A corresponding amount of evidence regarding the non- 
surgical treatment is not obtainable. True, appendi- 
citis must have been treated for many years medically, 
before the surgery of the appendix was ever introduced. 
At that time, however, the pathology of this condition 
was practically unknown, and its differentiation from THE CONSERVATIVE TREND. 
9 
other conditions, such as general peritonitis, obstruc- 
tion of the bowels, faecal impaction, typhoid fever, etc., 
was so utterly obscure that accurate data were never had, 
and retrospective diagnoses and records are utterly un- 
reliable. Since its recognition as a distinct disease, on the 
other hand, the fashionable treatment has been so largely 
surgical that we are just now beginning to acquire medi- 
cal statistics for scientific comparison. The result of 
these researches is an unmistakable trend toward con- 
servatism. A few years ago the almost universal doc- 
trine was “ surgery alone and surgery immediately.” 
It is to be hoped that we will never drift back to the old 
do-nothing course. A judicious selection of cases, how- 
ever, and a correct decision as to the time for operation 
in the various forms, are worthy of thought and honest 
discussion. Says Hunter McGuire, in a recent paper on 
this subject: “ I am not always in a great hurry to oper- 
ate, but I am inclined to wait for the more acute symp- 
toms to wear off, and operate, if at all, after suppura- 
tion has taken place or during the quiescent stage be- 
tween the attacks. I wish my voice was strong enough 
just here to call a halt to the men who say, ‘ Operate 
at once—not this afternoon, or to-morrow, but now, in 
all cases when the disease is recognized.’ ” Concerning 
the class of cases for operation, Herbert W. Page says: 
“ Increasing experience shows that the affections of the 
appendix which call for surgical intervention fall into 
two main classes: (1) those in which there is perforation 
by a concretion, and (2) those in which the appendix 
has had its lumen temporarily obstructed by kink or 
cicatricial contraction, so as to cause retention of mucus 
and faeces, which lead to inflammation in and around it. 
The former cases are the more serious and call for early 10 
THE CONSERVATIVE TREND. 
operative measures in order to evacuate local collec- 
tions of pus; the latter are to be dealt with in periods 
of quiescence, when the disturbance of adhesions is less 
likely to be dangerous, and aseptic conditions can be 
more readily secured.” 
Senn very tersely summarizes his position in the 
following words: “ The custom followed by many Ameri- 
can 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 he limited to (1) 
those cases in which during the first attack symptoms 
arise which portend danger to life, and (2) to relapsing 
appendicitis. Some cases of appendicitis yield to medi- 
cal treatment, and in a large percentage of such cases 
the patients remain free from a second attack.” These 
expressions suffice to indicate the judgment of some of 
our best men both at home and abroad. There are, how- 
ever, many other surgeons of unquestioned ability 
who still retain radical views. A sound conservatism 
is undoubtedly desirable and will soon, I believe, be 
unchallenged. I have no sympathy, however, with the 
willful ignorance of those who state that ninety per cent, 
of all cases of appendicitis will get well without surgi- 
cal intervention. 
Extirpation of the Uterus and Ovaries.—A 
few years ago I heard an able gynecologist say that “ the 
only gynecology was surgical gynecology.” His state- 
ment was in pretty accurate accord with the work of the 
gjmecologist of that time. The long-established cus- 
toms of medical therapy in the diseases of the female 
generative organs was practically abandoned, nay, even 
ridiculed, and surgery ran rank and wild. The craze 
for operative records seems to have clouded entirely the THE CONSERVATIVE TREND. 
11 
conscience and high moral tone of our profession. The 
remotest future possibility of danger alike with evident 
present necessity was considered justifiable indication 
for the extirpation of organs whose vital importance to 
the physical, mental, and moral welfare of woman is 
immeasurable. Given a pain or other evidence of disease 
of the female generative organs, however trivial, and 
forthwith the far-seeing surgeon pictured to his mind, 
and to that of his victim, visions of most alarming future 
calamity and miserable death, unless these threatening 
organs were at once removed. An ovarian neuralgia, 
visions of pus sacs—an urgent oophorectomy. A minute 
fibroid, sarcomatous degeneration—hysterectomy. How 
many a woman in apparently absolute health and with 
prospects of a long and happy life before her has found 
a premature grave from our surgical zeal! How many 
more have on slightest or no provocation been unsexed 
and unstrung! Is it not time for the manhood as well as 
the science of our profession to call a halt to such work? 
To their credit he it said, many of the leading gynaecolo- 
gists are themselves beginning to sound the note of re- 
treat; and nothing is more apparent in the literature of 
pelvic surgery in the past year than a distinct trend to- 
ward scientific conservatism. 
In the recent edition of the American Yearbook of 
Medicine and Surgery, under the head of Diagnosis of 
Pelvic Inflammatory Diseases, occurs the following ex- 
pression: “The profession at large is awakening to the 
fact that a very large proportion of tubes and ovaries are 
annually uselessly sacrificed either to an absolute inabil- 
ity on the part of the operator to recognize the true con- 
dition, or to a culpable neglect on his part to accomplish 
an absolute diagnosis.” 12 
THE CONSERVATIVE TREND. 
How often has a laparotomy been made with but 
the slightest effort to ascertain the condition present; 
and when perfectly healthy, or at the furthest hut slight- 
ly damaged organs were found, they were nevertheless 
removed lest they cause some subsequent trouble, and to 
justify to the patient the ignorant and careless work of 
the operator, who must show some trophy of his butchery! 
In the light of these facts it is a gratifying indication to 
receive from the pen of so well-known a gynaecologist 
as Howard A. Kelly, of Johns Hopkins University, the 
following expression: “ Conservatism is undoubtedly the 
progressive spirit of gynaecology; exsective and amputa- 
tive gynaecology has gone to its extreme limits, and the 
more thoughtful surgeons looking at all the questions 
involved, in their broader aspects, have already sounded 
the keynote of the new advance.” The rule for operative 
interference in fibroids given by Mr. Champneys, presi- 
dent of the London Obstetrical Society, may well he 
given a broader application to all conditions indicating 
radical procedure. Says he: “The number of cases in 
which operation is justifiable or desirable must, gener- 
ally speaking, be regulated by the ascertained risks of 
the tumor [or disease] against the ascertained risks of 
the operation; the former must exceed the latter before 
operation could he justified.” Life must be reckoned as 
the first object of our care, to be hazarded only on most 
certain indications. 
But not alone in the decreasing number of capi- 
tal operations has conservative thought manifested 
its influence. The second care of true conserva- 
tism is in the preservation of function. The rapid mul- 
tiplication of more conservative methods and measures 
in operating is in line with the recognition of this princi- THE CONSERVATIVE TREND, 
13 
pie. If surgery be indicated at all, let it be the 
simplest and safest and the least disturbing to function 
consistent with the subsequent welfare of the patient, 
is a doctrine which certainly appeals to our judgment 
as well as to our conscience, and at last we are beginning 
to appreciate its weight. Among these conservative 
measures, replacing more radical ones, may be enumer- 
ated the following, as cited by Kelly in the paper above 
alluded to: 
1. Resection of diseased ovaries and opening and 
draining tubes, instead of extirpation of these organs 
(Polk). 
2. Myomectomy as a substitute for hystero-myomec- 
tomy (Dudley). ; 
3. Opening and draining pelvic abscesses, posterior 
to the uterus, through the vagina instead of by the ab- 
dominal route (Henrotin). 
4. Vaginal drainage in some cases of extra-uterine 
pregnancy in place of abdominal extirpation (Kelly). 
5. Excision of both large and small parovarian cysts 
without sacrificing ovary and tube (Kelly). 
And to these might be added— 
6. Curettement and packing of the interior of the 
uterus in all cases of subacute or chronic tubal disease, 
rather than premature excision of the affected tube 
(Polk). 
A most eloquent tribute to the success of conserva- 
tism in dealing with the appendages is the record of 
thirty-two childbirths in twenty-nine women whose ap- 
pendages were conserved; surely an object lesson which 
the thoughtful surgeon should not soon forget. 
And thus it will be seen that all along the lines in sur- 
gery a conservative trend is apparent. We are now sift- u 
THE CONSERVATIVE TREND 
ing the gems from the sands we have shoveled in past 
years, and separating the true from the false doctrines 
of modern surgery. The most precious metals are in 
mining found oft mixed with many that are dross; and 
no true progress is ever made in life without mistakes 
along the way. The day of extreme radicalism is passing 
fast; hut, had it never dawned, the sunlight of to-day’s 
conservatism would never have shown through Igno- 
rance’s sable cloud. The New York Medical Journal. 
A WEEKLY REVIEW OF MEDICINE. 
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