1896.] 
LIMITS OF THE ART OF SURGERY. 
905 
the last twenty-five years, and the knowledge thus 
gained has enabled the surgeon to prevent in a large 
measure the former and to treat intelligently and with 
increased success the latter. Many of the most noted 
surgeons who have left a strong and permanent 
impression on surgical literature and practice during 
the last quarter of a century have been 
and practical bacteriologists and competent pathol- 
ogists. The wonderful development of operative suit 
gery during the same time is one of the earliest and£j 
richest fruits reaped from the vast and fertile fieljj£ 
sown and cultivated by bacteriologists of every civile 
ized nation. To the immortal Lister belongs tHa-1 
honor of having opened a systematic and successful 
crusade against the surgeon’s most treacherous enemipf ' 
—the pathogenic microbes. The great principles 
he conceived and introduced into practice created a nayT 
era in surgery. Antiseptic surgery is one of the many- 
fruits of his genius and the one, to whom we as a 
sion and humanity owe more than to any other surgepn 
dead or living, has been permitted to live long enough 
to see the creation and blessings of aseptic surgery, 
the handiwork of his innumerable enthusiastic follow- 
ers. Antiseptic and aseptic surgery have smoothed 
the rough and rugged pathway of the practical sur- 
geon. Ordinary cleanliness has given way to surgical 
cleanliness. The almost universal introduction of 
antiseptic and aseptic precautions in the treatment of 
wounds in private and hospital practice has nearly 
eradicated the three greatest enemies of the surgeon 
of old, namely, hospital gangrene, erysipelas and sec- 
ondary hemorrhage, and minimized the occurrence of 
suppuration and its manifold immediate and remote 
complications. 
No wonder that a sense of security created by such 
wonderful changes made the surgeons bold. In con- 
sequence of such revolutionary changes wrought in 
the practice of surgery new territories were invaded 
and organ after organ, the seat of injury or disease, 
were subjected to direct surgical intervention. Step 
by step the scalpel found its way into localities where 
formerly the physician had reigned alone and supreme, 
and where its presence would have been regarded by 
him as convincing proof of homicidal intent. No 
better evidence can be advanced to show the difference 
in the kind and scope of work of the surgeon of to-day 
with the one before the pre-antiseptic time than a com- 
parison between the works of operative surgery of now 
and then. The sense of safety which took possession 
of the surgeon and an earnest desire to extend his 
skill to the successful treatment of affections which 
had heretofore baffled the efforts of the physician, 
brought on a warfare on almost every organ the seat 
of real or imaginary disease. The physician found 
himself suddenly out of his long time honored routine 
practice. The specialists utilized the opportunity and 
left no stone unturned to extend their sphere of activity. 
Brain surgeons, abdominal surgeons, neck surgeons 
appeared on the scene and filled the medical press 
with accounts of .their wonderful surgical feats. The 
old-fashioned gynecologist, whose chief occupation 
consisted in introducing and removing pessaries, 
cauterizing so-called ulcers of the cervix, swabbing 
out the uterus and inserting medicated vaginal tam- 
pons,became restless and anxious to exchange harmless, 
bloodless measures for the knife and scissors. His 
desire for bloody operations was not satisfied by sew- 
ing lacerations of the cervix and perineum. He felt 
that in order to keep abreast with the spirit of the 
ON SOME OF THE LIMITS OF THE ART 
OF SURGERY. 
Delivered at the Forty-seventh Meetiug of the American 
Medical Associatiyn>>*'3ftlauta, Ga., May 5-8,1896. 
BY N. SENN, M.D., Ph.D., LL.D. 
PROFESSOR OF PRACTICE OF SURGERY AKD CLINICAL SURGERY' IN RUSH 
MEDICAL COLLEGE ; ATTENDING SURGEON PRESBYTERIAN HOSPITAL; 
SURGEON-IN-CHIEF ST. JOSEPH’S HOSPITAL. 
Mr. President and Members of the American Med- 
ical Association:—Modern surgery has attained a 
degree of development which entitles it to the distinc- 
tion of a science and an art. As a science surgery is 
of recent date, having been founded and perfected 
during the last half of the present century. As an 
art it has been practiced for centuries by our ancestors 
with credit to themselves and benefit to the injured, 
the crippled and the sick. When Boyer wrote the 
introduction to his classic work on surgery he ex- 
pressed the conviction that surgery had reached per- 
fection. How little did he dream of the great changes 
that would be wrought in the practice of his cherished 
profession by the progressive pathologists and surgeons 
of the next few generations! How innocent and absurd 
does such a statement appear in the face of the labors 
of such men as Virchow, Rokitansky, Rindfleisch, 
Klebs, Recklinghausen, in pathology; Pasteur, Koch, 
Ogsten, Rosenbach, Baumgarten, in bacteriology; 
Lister, Langenbeck, Billroth, Hueter, Esmarch, 
Czerny, Gussenbauer, Nelaton, Verneuil, Terrier, 
Macewen, Gross, Agnew, in surgery; Terrier, Hitzig, 
Horsley, in cerebral localization; Spencer, Wells, 
Keith, Winckel, Martin, Pean, Segond, Pozzi. Sims, 
Emmet, Battey, in gynecology, and a host of other 
faithful unselfish__workers who have made surgery 
what it is to-day and what it is intended to be, the 
most honored, respected and beneficent branch of the 
healing art. What a contrast between the standing 
of the surgeon of to-day in the community, the pro- 
fession and from a scientific asjdect as compared with 
his colleagues of only a century ago! It is not long 
since the art of surgery was limited to bleeding, cup- 
ping, leeching, setting of a broken limb, reducing a 
dislocation, stanching hemorrhage, opening an abscess 
or amputating a limb for injury or disease beyond the 
reach of conservative measures. He was the subor- 
dinate, almost slave, of the pompous, arrogant and 
self-confident physician of that time. He subsisted 
from the crumbs that fell from time to time from his 
master’s table. The betterment in the standing and 
sphere of the members of the surgical craft during 
the last century is entirely due to the enormous 
progress that has been made in the science and 
art of surgery. During this time the legitimate field 
of medicine has gradually diminished before the 
advancing columns of progressive and aggressive sur- 
geons. The physician no longer has a monopoly over 
the diseases of all the internal organs. The physician’s 
distinctive apparel and gold-headed cane of but few 
years ago no longer intimidate the surgeon; they have 
disappeared from the scene and the surgeon stands 
on the same level, if not higher, in every respect with 
the physician in the eyes of the masses and the esti- 
mation of the scientific world. Modern pathology 
and the new science of bacteriology have laid a per- 
manent foundation for the steady and progressive 
advance of surgical thought and work. The inflam- 
matory complications of wounds and the etiology of 
most of the chronic infective surgical diseases have I 
been cleared up by bacteriologic investigations during I 906 
LIMITS OF THE AET OF SUKGEEY. 
[May 9, 
present age he must increase his range of action, and in 
due course of time the ovaries, the Fallopian tubes and 
uterus became the theater of his aggressiveness. Even 
the acquisition of this additional territory did not 
satisfy his ambition. The adjoining great abdominal 
cavity, with its many important organs was looked 
upon with a jealous eye and it has been made the com- 
mon camping ground of the general surgeon and the 
gynecologist for several years. 
The throat and nose specialist, under the same 
influences, became disgusted with his brush, powder- 
blower and atomizers; sharp spoons, chisels and saws 
came into requisition, and the number of deflected 
septa, hypertrophic turbinated bones and third tonsil 
increased alarmingly and were attacked most ener- 
getically. The rectal specialist, who made a modest 
living by stretching the sphincter ani and ligating 
piles, saw a fortune in adding to his limited sphere of 
activity, resection of the rectum, and later, emboldened 
by his efforts carried his crusade to the topmost limits 
of the large intestine. The average orthopedist is no 
longer satisfied to correct deformities by the use of 
bloodless manual and mechanical measures; he has 
acquired a fondness for the knife, saw and chisel, so 
as not to be left behind in the procession. The genito- 
urinary surgeon has become tired of treating gonor- 
rhea, strictures and syphilis; he can see no reason 
why he should not cut for stone, extirpate kidneys and 
perform plastic operations on the ureters. 
The furor operativus manifested in these and other 
special departments of surgery, and its obvious results, 
render the standing and legitimate scope of the gen- 
eral surgeon very uncertain and indefinite at the 
present time. Let the general surgeon turn to the 
right or to the left, advance or retreat and he finds 
himself on reserved territory. As for the physician, 
he is expected to answer night calls, prescribe for 
diarrhea and whooping cough, watch cases of typhoid 
fever, measles, scarlatina and smallpox, and should 
complications arise and he does not report to the 
proper authority he renders himself liable to censure. 
Much of this ill-applied energy in the surgical world 
has resulted in detriment to patients and in retarding 
actual surgical progress. Operative surgery has been 
carried to extremes. A calm inspection of the ground 
that has been gone over will show “ Some of the Limits 
of the Art of Surgery,” the subject which I have 
chosen for this address. 
Antisepsis and Asepsis.—The marvelous reduction 
in the mortality following injuries and operations 
which the present generation has witnessed is largely 
due to the prevention of wound complications by the 
employment of efficient antiseptic and aseptic pre- 
cautions. Improved means of hemostasis and the 
more efficient treatment of shock might reasonably 
claim a certain share in bringing about such a desir- 
able change in the results of surgical practice, but 
what has made our work more satisfactory and the 
statistics of various operative procedures more encour- 
aging is the prevention of infection, the protection of 
the patient against the immediate and remote effects 
of sepsis and suppuration. The treatment of wounds 
with these objects in view has been simplified and 
rendered more efficient from year to year, but it can 
not be said that perfection has been reached. We are 
not yet in possession of an ideal absorbable ligature 
and suture material. The person who will show us 
how to prepare the animal ligature and suture in such 
•a way that it will not oidy be absolutely aseptic but 
also antiseptic and without loss of its tensile strength, 
will be entitled to the lasting gratitude of the entire 
profession. The disinfection of hands and field of 
operation is open to future improvement. The im- 
portant matter of drainage remains in anything but a 
satisfactory condition and the questions frequently 
raised, when to drain and how to drain, must be defin- 
itely settled by future experience and research. There 
are surgeons to-day who do not take into account the 
possible failure of antiseptic and aseptic precautions 
in estimating the dangers incident to operative pro- 
cedures. Have we not all heard so-called abdominal 
surgeons say that an exploratory laparotomy is devoid 
of danger? Is it not a fact that the abdomen is being 
opened daily by men wdio have not the faintest idea of 
what they may have to do, simply because they regard 
such a step as harmless and free of danger and the 
shortest and easiest wmy to make a diagnosis? To say 
that such a blind confidence in the efficiency and 
safety of aseptic precautions is not in accord with the 
wTork of the conscientious surgeon is to put it mildly. 
It is fortunate for the patients of such ever-ready and 
self-confident operators that the peritoneum under 
ordinary circumstances can dispose of more pathogenic 
microbes without harm resulting than any other tissue 
of the body. If it were not such a serious matter it 
would be amusing to see how such men explain an 
occasional death that occurs in their practice in cases 
where it was least expected. If, perchance, a post- 
mortem examination was held, the first statement made 
is that the peritoneum showed no evidences of inflam- 
mation, consequently death must have occurred in 
consequence of shock, exhaustion, bronchitis, edema 
of the lungs, or heart failure. Very recently a prom- 
inent surgeon in giving his testimonial in recommend- 
ing a certain kind of catgut, made the statement that 
he had performed one hundred consecutive major 
operations without having seen a single drop of pus. 
I have no reason to doubt the veracity of this gentle- 
man’s statement, but I am firmly convinced that it 
would be difficult, if not impossible, to duplicate such 
an experience in the practice of the average general 
surgeon. 
I have made it a duty on my part to familiarize 
myself with the advances made in the technique of 
aseptic surgery and have the good fortune to perform 
all my operations in two of the best hospitals in Chi- 
cago and in a fairly wTell equipped college clinic, and 
yet I am only too willing to confess that I never fin- 
ish my day’s work without seeing pus. I have a pain- 
ful recollection of twTo amputations for carcinoma of 
the breast on private patients, in both of which every 
possible precaution was carried out, and yet to my 
utmost disappointment, both of them died of the most 
virulent form of sepsis I ever encountered. To offset 
these cases I might refer to perhaps over two hundred 
similar operations in which, under much less rigid 
precautions, with few’ exceptions, faultless wound 
healing was obtained. I remember, too, a case of 
genu valgum in an adult treated by transcondyloid 
osteotomy under strict antiseptic precautions, where 
the operation was followed by violent suppurative 
osteomyelitis and extensive necrosis which for a long 
time seriously threatened the limb and life of the 
patient. I am sure that I am not alone in relating such 
experiences. Every surgeon is occasionally humili- 
ated by such mishaps and here is the proper place to 
make open confessions. The careless, reckless remark 
so often made by men who ought to know better, that 1896.] 
LIMITS OF THE ART OF SURGERY. 
907 
the surgeon who understands his business can make 
.and treat wounds which, if dressed properly, will heal 
without suppuration, has reached the ears of the legal 
profession and has already entangled many a worthy 
and honest member of our profession in the compli- 
cated and trying machinery of the law. I envy the 
surgeon who has implicit confidence in this or that 
method of preventing wound infection, but I am con- 
fident that I but voice the sentiment of the vast ma- 
jority of surgeons by making the statement that one 
of the limits of the art of surgery at the present time 
is the inadequacy of our available resources in fur- 
nishing wounds, even under the most favorable cir- 
cumstances, absolute protection against infection. 
Phlegmonous Inflammation.—The employment of 
antiseptic and aseptic precautions in the treatment of 
intentional and accidental wounds has greatly dimin- 
ished the frequency of progressive phlegmonous in- 
flammation and its often disastrous consequences 
That such an occurrence can not always be prevented, 
even by the most scrupulous care and attention to 
details, every surgeon of experience is willing to admit. 
In the most virulent forms of phlegmonous inflamma- 
tion the most heroic and timely treatment, local and 
general, is often fruitless in averting speedy death. 
In the most desperate cases the surface lesion is often 
insignificant, the infection following the lymphatic 
pathways, soon reaches the general circulation result- 
ing in death from acute sepsis before any decided 
gross pathologic lesions have appeared at the seat 
of infection or in any of the internal organs. How 
rapidly general infection may take place has been 
shown by the experiments of Schimmelbusch, who 
found microorganisms in the spleen five to ten min- 
utes after infection of a wound. Colin and Niessen 
demonstrated by their experimental work that ampu- 
tation a few minutes after inoculation, of the ears and 
limbs of rabbits with pure cultures of anthrax, did not 
protect the animals against generalization of the dis- 
ease. Such cases in the human being fortunately are 
seldom met with, but when they do occur, the art of 
; surgery is powerless in arresting the progress of the 
disease. Parenchymatous injections of solutions of 
carbolic acid or corrosive sublimate along the course 
of the inflamed lymphatics, and the internal use of 
alcohol in heroic doses promise the most, but in the 
great majority of cases the extension of the infection 
continues and terminates speedily in death from gen- 
eral sepsis. Whether bacteriology will furnish us 
with a more potent weapon in the treatment of such 
cases the future must determine. When the infection 
has resulted in suppuration the old adage ubi pus ibi 
incisio remains as true to-day as before the microbic 
origin of pus was known. In the treatment of diffuse 
phlegmonous processes it is now customary to make 
free incisions, establish free drainage and disinfect 
the cavity by flushing it freely with a safe and yet 
efficient antiseptic solution, such as a saturated solu- 
tion of acetate of aluminum, a 3 per cent, solution of 
carbolic acid or a 1:5,000 solution of corrosive sub- 
limate and apply to the part hot compresses wrung 
out of the same solution. A few years ago Helferich 
advised laying open of the entire cavity by a single 
incision, recently Kocher pleads in favor of small 
incisions for the reason that pus microbes multiply 
more rapidly when freely supplied with oxygen. I 
believe the best treatment is half way between these 
two extremes, that is, multiple incisions large enough 
to insert drains the size of the little finger with a view 
of establishing a perfect system of drainage. We can 
not expect much from a single disinfection. In 
severe cases in which life is threatened by sepsis I 
invariably resort to continuous irrigation with a satu- 
rated solution of acetate of aluminum, a non- 
toxic and yet very efficient antiseptic agent. The 
inflamed part should be immobilized and maintained 
in an elevated position until the inflammatory edema 
has subsided. The same treatment yields the most 
happy results in the treatment of acute suppurative 
inflammation of the large joints. One of the great 
shortcomings of the art of surgery to-day is the lack 
of measures to deal more efficiently with progressive 
suppurative affections and secure for suppurative cav- 
ities an aseptic condition in a shorter and more direct 
way. In cases of circumscribed abscesses it is gener- 
ally believed that the sooner the incision is made the 
more prompt will be the relief and the more speedy 
the cure. Clinical experience has not confirmed these 
expectations. The old surgeons applied emollient 
poultices until the abscess became soft before they 
used the bistoury. No modern surgeon has any use 
for the filthy germ-breeding poultice, for which he has 
substituted the antiseptic, moist, hot compress which 
answers the same purpose, as it furnishes the neces- 
sary heat and moisture, and at the same time pre- 
pares the surface for the incision. We are, however, 
almost as powerless as our forefathers in limiting, 
much less aborting, a suppurative inflammation. One 
of the greatest and most useful innovations in surgery 
would be a remedy, local or general, which would 
enable us to abort the process of destruction after the 
classical symptoms which characterize suppurative 
inflammation have set in. We must look to bacte- 
riology to fill up this most important gap. 
Acute Suppurative Osteomyelitis—Closely allied 
to phlegmonous inflammation of the soft tissues is 
acute suppurative osteomyelitis as it is caused by the 
same kind of microbes and results in more or less 
extensive destruction of tissue. The etiology and 
pathology of this disease are now well understood and 
upon them is based the early operative treatment 
which is generally endorsed by the profession at the 
present time. The danger from general sepsis is 
greater in the more serious forms of osteomyelitis 
than a similar affection of the soft tissues owing to 
the location of the primary focus of infection and the 
frequency with which the adjacent large joints become 
implicated during the progress of the disease. The 
early removal of the osteomyelitic product by opera- 
tive interference as a rule relieves pain promptly, 
limits necrosis, guards against joint complications and 
minimizes the danger from general sepsis. Immobil- 
ization of the affected limb in proper position and 
the exposure of the osteomyelitic focus by the use of 
the chisel or gouge as soon as a positive diagnosis can 
be made are the modern resources which have suc- 
ceeded in greatly reducing the mortality of this dis- 
ease as well as its immediate complications and remote 
consequences. There are, however, cases of acute osteo- 
myelitis in which the earliest intervention of the art 
of surgery is powerless in preventing death from gen- 
eral sepsis. These are the cases of osteomyelitis in 
which simultaneously or in rapid succession a number 
of the long bones become involved and where the local 
signs and symptoms are overshadowed by the general 
symptoms which point to a progressive sepsis and 
which are so seldom favorably influenced by either 
local or general treatment. 908 
LIMITS OF THE ART OF SURGERY. 
[May 9, 
Tuberculosis of Joints.—Only a few years ago the 
surgeons who paid special attention to diseases of the 
joints were enthusiastic advocates of early resection or 
arthrectomy in cases of tubercular joint affections. 
Typical resections were made regardless of the anato- 
mical location or the extent of the disease. It was 
believed that such medical treatment would succeed 
in eliminating the local affection and in preventing 
the extension of the infection to distant organs by 
reinfection from the peripheral focus. Statistics prove 
that these hopes are unfounded and conscientious and 
thinking surgeons have substituted largely in place of 
operative treatment conservative measures. The sur- 
geon forgets too often that tuberculosis of joints sel- 
dom appears as a primary affection but as a rule ap- 
pears as a peripheral manifestation of the existence of 
an antecedent perhaps undiscoverable tubercular affec- 
tion of another organ, hence the removal of the accessi- 
ble tubercular product does not necessarily protect the 
patient against tuberculosis of other joints or organs 
or general miliary tuberculosis. It is on the other 
hand a familiar clinical fact that the operative treat- 
ment of joint tuberculosis has not infrequently been 
followed by tuberculosis of other organs or general 
miliary tuberculosis. The short-comings of the art of 
surgery are well brought forward in the treatment of 
tubercular joints. In large clinics where but a few 
years ago resection of joints for tuberculosis was a 
daily occurrence such operations are now rarely wit- 
nessed. This change in practice is largely due to the 
beneficial effects obtained from intra-articular and 
parenchymatous injections of iodoform glycerin in- 
jections. I have resorted to this treatment in hun- 
dreds of cases with the most satisfactory results. In 
about one-half or two-thirds of all cases of uncompli- 
cated joint tuberculosis this treatment proves curative. 
It is of special value in the treatment of tubercular 
abscesses in communication with a tubercular joint or 
bone. From one to three or four injections usually 
suffice in obliterating the abscess cavity. The tap- 
ping and injection must be done under the strictest 
antiseptic precautions lest the operation will aggra- 
vate the case, perhaps render it hopeless, by becoming 
the direct cause of a mixed infection with pus mi- 
crobes. As some persons are peculiarly susceptible 
to the toxic action of iodoform the minimum dose 
two drachms of a 10 per cent, emulsion should be used 
in the beginning. In cases complicated by renal 
affections this caution should be increased as any 
affection of the kidneys retards the elimination of the 
iodoform and thus increases the danger from intoxica- 
tion. Another important precaution in tapping a 
tubercular abscess is not to puncture the skin where 
it is thin and cyanotic as when it is made in such a 
place the puncture is very liable to give rise to a fistu- 
lous opening and consequently increased risk of infec- 
tion with pyogenic microbes. The puncture must 
be made through normal skin, if need be some distance 
from the abscess, and after removal of the canula it 
should be sealed with iodiform collodium and a small 
pledget of sterile cotton. Immobilization of the limb 
or part thus treated is often useful but not always 
necessary. During the process of repair initiated by 
the iodoform injections the capsule of the joint often 
undergoes great contraction which if not counter- 
acted by an appropriate mechanical support may 
result in a deformity difficult of correction short of 
operative interference. In cases of joint tuberculosis 
in which this treatment does-not succeed in effecting 
a cure it will prove to be the best possible prelimin- 
ary treatment to a successful arthrectomy or atypical 
resection. Iodoform is absolutely useless in the treat- 
ment of tubercular affections complicated by suppur- 
ation. The antibacillary effect of iodoform in such 
cases only asserts itself after the pyogenic product and 
its causes have been eliminated by operative measures 
or chemical disinfectants or by a combination of these 
two antiseptic resources. In cases in which the iodo- 
form treatment fails or in which it is contraindicated, 
arthrectomy and atypical resection have been largely 
substituted for typical resection. 
Malignant Tumors.—The imperfections of the art 
of surgery become very apparent in the treatment of 
far-advanced malignant disease of any part or organ. 
The essential cause of carcinoma and sarcoma remains 
to be discovered. The science of surgery must first 
divulge the true nature of tumors before we can expect 
a decided advance in their more successful treatment. 
The essential features of the modern treatment of 
malignant tumors may be summed up very briefly as 
follows: Operate early and thoroughly. The treat- 
ment of unoperable sarcoma by injections of the ster- 
ilized toxins of the streptococcus of erysipelas and the 
bacillus prodigiosus has not filled the expected results. 
In my paper on this subject read in the Surgical Sec- 
tion of this Association at the last meeting I gave the 
results of my experience with this treatment. An 
additional experience since that time only confirms 
my views expressed at that time concerning the utter 
lack of curative power of these toxins in the treatment 
of genuine cases of sarcoma. The microscope is no 
infallible means of diagnosis in differentiating between 
small round celled sarcoma and some of the granulo- 
mata. The curative effect of a remedy can not be 
established unless an absolutely correct diagnosis can 
be made of the disease in the treatment of which it is 
employed. The discovery of some remedy, which by 
its local or general action would correct erratic cell 
growth and transform embryonic into mature cells 
might possibly change malignant into benign tumors 
and by doing so deprive them of their malignant clin- 
ical tendencies. Experimental researches in this 
direction might possibly lead to a rational treatment 
of malignant tumors short of a resort to the knife or 
caustics. At the present time the surgeon’s resources 
in the treatment of malignant tumors are largely lim- 
ited to an early and thorough use of the knife. Every 
surgeon deplores the fact that with the exception of 
carcinoma of the lip or of parts similarly exposed the 
patients who apply to him for surgical treatment with 
few exceptions are suffering from malignant tumors, 
which extend beyond the organ primarily affected and 
have given rise to regional dissemination, general met- 
atasis or both. For instance, of the over 200 cases of 
carcinoma of the breast which have come under my 
own observation I remember only one case in which 
during the operation, the axillary glands were found 
unaffected and in this case the columnar celled car- 
cinoma, the size of a pea, had obstructed a duct, in 
consequence of which a retention cyst the size of a 
walnut developed, for which the patient applied for 
treatment. In cases of carcinoma of the uterus that 
come to me for examination and treatment, I find that 
only one out of every eight or ten cases is a proper 
case for a radical operation. In more than one-lialf 
of my cases of carcinoma of the rectum I refuse extir- 
pation of the affected organ, and advise in its place an 
inguinal colostomy, because the disease has extended 1896. 
LIMITS OF THE ART OF SURGERY. 
909 
to the pelvic connective tissue, the retro-peritoneal 
lymphatic glands or adjacent organs. Of eighteen 
cases of pyloric carcinoma of the stomach subjected 
to operative treatment, I found the disease limited to 
the part primarily affected oidy in one case; in the 
remaining cases the disease had extended invariably 
to the lymphatic glands, and in some of them to the 
adjacent organs, liver, gall-bladder, pancreas, omen- 
tum and colon. It is the operative treatment of 
advanced cases of malignant disease that brings so 
little benefit to the patient and so much disappoint- 
ment to the surgeon. Asepsis and a greatly improved 
operative technique have done much to improve the 
results of operative treatment of malignant tumors, 
but they have not succeeded in doing away with well 
recognized restrictions upon the art of surgery to 
which I now desire to call your attention. There is 
perhaps, no other department in surgery which 
presents more diversity of opinions than the selec- 
tion of cases of malignant tumors for operative treat- 
ment. 
The conscientious surgeon looks as carefully for 
contraindications as for indications for radical opera- 
tions. He is concerned more for the welfare of his 
patient than his own selfish interests. A prospective 
liberal fee has no influence in changing Ids decision. 
He makes a careful examination of his patient, the 
tumor and its environments, before he recommends 
an operation. He has learned from sad experience 
that aside from justifiable palliative operations for 
obstructive malignant affections, imperfect operations 
have proved as detrimental to his patients as to his 
reputation. He looks the ground over carefully before 
he decides to attempt a radical operation. The squeez- 
ing out of a fixed carcinomatous uterus between forc-i- 
pressure forceps is not likely to prolong the life of 
the patient or increase the reputation of the surgeon 
who ignores to such an extent the limits of the art of 
surgery. The removal of a carcinomatous breast 
without a thorough clearing out of the axillary space 
may increase for the time being the bank account of 
the operator, but it will surely prove a detriment to 
the patient. The partial or complete excision of the 
rectum for carcinoma complicated by regional infec- 
tion is an operation attended by great immediate 
risk to life without a ray of hope of effecting a per- 
manent cure. Such bold and reckless overstepping of 
the limits of the art of surgery is not calculated to 
increase the estimation of our profession in the eyes 
of the public or to receive the sanction of the consci- 
entious, discriminating surgeon. The radical removal 
of a malignant tumor means more than the extirpa- 
tion of the primary tumor; it means the removal of 
every malignant ceil, whether in the immediate vicin- 
ity of the primary growth or in the same region. 
Evidences of distant metastasis furnish a positive 
contraindication to operative interference. Regional 
dissemination beyond the reach of complete removal 
of every vestige of tumor tissue, local and regional, 
without imminent risk to life, constitutes an equally 
forcible argument against a radical operation. Large 
surface defects made by extensive radical opera- 
tions should always be covered by a plastic opera- 
tion or by Thiersch’s method of skin grafting. It 
has always been my aim to cover the wound with skin 
by either of these methods immediately after the 
extirpation of the tumor for the purpose of securing 
healing by the first intention, as' I am satisfied that 
the slow process of healing of large surface defects 
by granulation, cicatrization and epidermization is 
conducive to an early local recurrence. 
Surgery of the Three Great Cavities— The sys- 
tematic invasion of the three great cavities of the 
body for the treatment of injury or disease is one of 
the great triumphs of modern surgery. Our ances- 
tors entertained a well-founded dread for operations 
which necessitated opening of any of the great serous 
cavities, knowing from experience their great suscep- 
tibility to septic infection. Recent experience has 
shown that any of these cavities can be opened for 
diagnostic or therapeutic purposes without much 
danger provided the operation is performed under 
strict antiseptic precautions. The prevention of septic 
complications by asepsis has been the means of cre- 
ating visceral surgery. The sense of safety in sub- 
jecting the different viscera to direct operative treat- 
ment which has taken possession of the profession has 
enlarged to a wonderful extent the field of operative 
surgery, but it has carried at the same time the work 
of the ambitious enthusiastic surgeon beyond the 
limits of his art. Many of the bold attempts upon 
the organs of the three great cavities are far beyond 
the legitimate restrictions established by the science 
of surgery. The maida for achieving new victories 
outside of the sphere of legitimate rational surgery 
has neither brought lasting reputation to the adven- 
turers nor benefit to suffering humanity. Many of 
the new operative procedures remind one more of 
sensationalism than the product of mature, deep sur- 
gical reasoning. The accounts of new operations that 
are being constantly devised have left operative sur- 
gery in a state of confusion. Works on operative 
surgery that left the press six months ago are obsolete 
or at least unsatisfactory to-day. The technique of 
nearly every operation is constantly undergoing 
changes by the addition of important or unessential 
modifications. Nearly every surgeon has a flaming 
desire to connect his name with an instrument of his 
invention, a new operation or a modification of an old 
one. A new operation is devised, a case is found upon 
which it is tried, and if the result is in any way favor- 
able an account of it is sure to find its way promptly 
into the current medical literature. Many members 
of the medical profession are willing and ready imi- 
tators, who are always anxiously waiting for new dis- 
coveries and improvements, ever ready to apply them 
in their practice without questioning their utility or 
justifiability. This blind imitation of the practice of 
others has been the source of great harm to confiding 
patients and has exerted a powerful inhibitory effect 
on the true progress of surgery. This is an age of 
bold surgery. The surgeon who is careful in the 
selection of his cases, slow and painstaking in liis 
work, need not look for recognition on the part of his 
students or colleagues; it is the man who lays the 
abdomen open by a single stroke of his knife, removes 
two healthy ovaries and closes the incision and returns 
his patient to her room in seven minutes, who com- 
mands the attention of his audience and bears with a 
self-confident dignity the proud distinction of being 
a bold and brilliant operator. In calling your atten- 
tion to the limits of the art of surgery in the treat- 
ment of injuries and diseases of the organs contained 
in the three great cavities, time will only permit to 
point out a few of the most flagrant transgressions of 
the established principles of surgery during the last 
few years. 
Surgery of the Skull and Brain. The use of the 910 
LIMITS OF THE ART OF SURGERY. 
[May 9, 
trephine in the treatment of fractures of the skull 
has had a varied experience since the time of Hip- 
pocrates. Trephining of the skull for injuries is one 
of the oldest operations in surgery. From time to 
time strong arguments have been made against the 
indiscriminate operating for fractures of the skull. 
Stromeyer and his followers abandoned the operation 
of trephining, believing and claiming that the opera- 
tion resulted in more harm than good to the patient. 
It is not difficult to conceive that at that time the con- 
version of a subcutaneous into an open fracture was 
attended by great risks from infection. The mini- 
mizing of the danger from infection by aseptic pre- 
cautions again brought the trephine into general use 
not only in the treatment of fractures of the skull, but 
also in the treatment of pathologic intracranial lesions 
of a non-traumatic origin. Many surgeons now advo- 
cate trephining in all fractures of the cranial vault, 
claiming that the operation would reduce to a mini- 
mum the dangers from remote complications such as 
obstinate headache, epilepsy and insanity. The ques- 
tion arises, is such a position in consonance with 
rational surgery? Every surgeon knows that such 
remote complications after fracture of the skull not 
subjected to trephining are rather the exception than 
the rule. It is evident that operative interference in 
such cases has been carried to extremes. Even under 
the protection of aseptic precautions, the transforma- 
tion of a closed into an open fracture of the skull is 
attended by certain risks which no surgeon can afford 
to ignore and which must be taken into careful con- 
sideration before operative interference is determined 
upon. This advice applies with special force to the 
treatment of fractures of the skull in children, as in 
them spontaneous elevation of the depressed fragment 
or fragments is frequently observed during the process 
of repair. There is no rule in surgery without its 
exceptions, hence the advice to use the trephine in 
fractures of the skull with depression without regard 
to the age of the patient or the presence or absence 
of symptoms, lacks a moral as well as a scientific 
foundation. The art of surgery has its well-founded 
limits in the treatment of fractures of the skull. In 
my opinion, operative interference is absolutely indi- 
cated in fractures of the cranial vault under the fol- 
lowing circumstances: 1. All open fractures, includ- 
ing 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 depart- 
ment 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 
is 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 upon 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 inflam- 
matory affections of that part of the brain, but so far 
it has not yielded encouraging results. When Lanne- 
longue 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 opera- 
tion ? 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 microceplialic child, 
because I have always regarded the operation as use- 
less in promoting brain development. The responsi- 
bility 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 haz- 
ards. 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 responsi- 
bilities to Hod 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 sur- 
gery. This part of cerebral surgery will reach perfec- 
tion 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. 1896.] 
LIMITS OF THE ART OF SURGERY. 
911 
Surgery of the Chest.—Modem surgery lias 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 hy- 
drothorax 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 iodid 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 bril- 
liant results. The treatment of abscess of the lung 
by rib resection, free incision with the knife point of 
the Paquelin 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 serous investment, 
the pericardium. Tapping of the pericardium for 
serous effusion has become one of the established 
operations in surgery. A very few cases of pyoperi- 
cardium have been brought to a successful termina- 
tion 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 for- 
eign 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 sur- 
gery has done very little toward the successful treat- 
ment of injuries and diseases of this organ. Many 
have been the efforts of surgeons to supplant the phy- 
sician 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 legit- 
imate field of the physician has been followed without 
exception, by an ignominious failure. It is unfor- 
tunate, but true, that the surgical treatment of pul- 
monary tuberculosis by direct surgical intervention is 
beyond the present legitimate limits of the art of sur- 
gery. 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 sep- 
tic 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 con- 
tains 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 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 success- 
fully 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 expec- 
tations he entertained in regard to the benefits to be 
derived from direct surgical intervention in cases of 
carcinoma of the stomach, justifying surgical inter- 
ference. Notwithstanding the wonderful improve- 
ments in the technique of operations upon the stom- 
ach, partial gastrectomy and pylorectomy have 
yielded anything but encouraging results. In nearly 
50 per cent, the patients subjected to radical treat- 
ment 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 sev- 
eral 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 attempts at radical removal of the disease. The 
legitimate limits of the art of surgery in the treat- 
ment 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 primarly 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 malig- 
nant disease has extended to adjacent organs or after 
regional infection through the lymphatic glands and 
channels has taken place is tampering with the pres- 
ent limits of the art of surgery. The palliative oper- 
ations for carcinoma of the cardiac and pyloric ex- 
tremities of the stomach have yielded excellent results, 
and should receive the sanction of every surgeon who 
has the best interests of his patients at heart. Wit- 
zel’s operation for establishing an external gastric 
fistula in cases of malignant obstructive tumors at the 
cardiac orifice of the stomach, and Rockwitz-Wolfler’s 
operation for pyloric carcinoma are the palliative 
operations which promise the most with the least im- 
mediate risks to life in all cases of malignant tumors 
of the stomach which give rise to obstruction. The 
treatment of intestinal obstruction by surgical inter- 912 
LIMITS OF THE ART OF SURGERY. 
[May 1), 
vention has become an established custom. Physi- 
cians and surgeons imbued with a proper moral and 
scientific sense, recognize the importance of early sur- 
gical interference in all cases of intestinal obstruction 
due to mechanical causes. An early positive diagno- 
sis 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 divi- 
sion or excision of a constricting band in the treat- 
ment 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 opera- 
tions were postponed until the malignant disease 
gave rise to symptoms of obstruction, when it was 
usually found that the carcinoma had passed beyond 
the legitimate limits of a radical operation. The im- 
plication 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 trans- 
gression 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 anasto- 
motic opening between the intestine 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, Ramauge and 
Cliaput, which must pass the intestinal canal un- 
changed, is a procedure fraught with more or less 
danger, which is being recognized more as the expe- 
rience 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 prac- 
tice. The custom followed by many American sur- 
geons 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 symp- 
toms 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 patients remain free from a second attack. 
Pancreatic surgery at the present time is limited to 
the treatment of cysts by establishing and maintain- 
ing an abdominal fistula until the cyst becomes oblit- 
erated. The extirpation of pancreatic cysts and par- 
tial pancreatectomy for malignant disease are opera- 
tions 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 the 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 under- 
taking far beyond the present limits of the art of sur- 
gery. The successful treatment of abscess of the 
liver and echinococcus cysts by direct surgical inter- 
vention 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 tracts 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 cal- 
culus are now exposed and incised, the calculus ex- 
tracted 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 
a patient is suffering from gallstones does not fur- 
nish 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 oper- 
ative treatment present themselves. The surgeon 
who recorded the first successful case of cliolecystot- 
omy 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 fol- 
lowed by dilatation by the use of laminaria tents in 
the treatment of impacted stones and cicatricial sten- 
osis 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 
supplanted 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 satis- 
factory results. 
Organs of Generation.—The greatest onslaught of 
modern surgery has been upon the organs of genera- 
tion, 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 913 
1896.] 
LIMITS OF THE ART OF SURGERY. 
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 sci- 
-entific foundation. Here and there we hear a feeble 
voide protesting against the indiscriminate surgery 
upon the organs of generation of the opposite sex, but 
the mutilating work continues in spite of such oppo- 
sition and well-meant advice. Every competent and 
honest gynecologist knows that in his sphere the art 
of surgery has been thoroughly abused. It is diffi- 
cult 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 medi- 
cal men of this country for innumerable and inex- 
cusable 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 pen- 
etrated 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 can 
not 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 practi- 
tioners have their eyes on large cities and have heard of 
enticing fees paid to specialists for insignificant oper- 
ations. Why buy a horse and saddlebags when a fortune 
awaits them in devoting themselves to a specialty, more 
particulary gynecology? Th£ 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 grand- 
mother that a few days before they had consulted a 
young gynecologist, who made a hasty vaginal exam- 
ination, looked wise and informed them that he had 
found the source of all trouble in the form of a lacer- 
ation 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 with- 
out 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 ap- 
plied for treatment; others are less fortunate. Suffer- 
ing woman will believe in and submit to almost every- 
thing. In fact it has become almost a fashion for 
women suffering from real or imaginary affections of 
the genital organs to consult a gynecologist as reg- 
ularly as her dentist or dressmaker. Not long ago a 
girl 18 years of age was brought to me with the infor- 
mation 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 gyne- 
cologist. 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 imag- 
inary ailments 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 gyne- 
cologists physically and mentally in a better condi- 
tion 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 vener- 
able and distingnished Emmet devised his 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 conso- 
nance 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 or seven minutes still serves as 
an attraction for the lookers-on in many private hos- 
pitals and gynecologic clinics. I fully appreciate the 
value of a well-performed perineorrhaphy in proper 
cases, but I am equally well satisfied that the opera- 
tion 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 914 
LIMITS OF THE ART OF SURGERY. 
[May 9, 
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 fre- 
quency 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 oper- 
ator 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 
Graafian follicle is discovered, when he consoles him- 
self 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 wil- 
lingly sacrificed 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, tube- 
less 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 remain- 
ing after removal of their appendages have been 
removed in a vain hope of securing permanent relief. 
Vaginal hysterectomy for diseases other than carci- 
noma is now at its height. The uterus is being 
removed for hypertrophy, endometritis, flexion, ver- 
sion 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 affec- 
tions or inflammatory lesions of adjacent parts, do so 
by the use of compression forceps. It is no great sur- 
gical 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 gynecologists. 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 impos- 
sible 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 por- 
trayed 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 first apply for relief. Let them do their 
duty toward their patients. Many of the minor affec- 
tions of tlie uterus and its appendages are within the 
reach of intelligent general and local treatment with- 
out 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 undiscrim- 
inate operating upon the female organs of genera- 
tion 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 can not dismiss the subject of genital surgery with- 
out 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 posses- 
sion 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 urinary obstructions due to such a 
cause. About the same time Hamm 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 cura- 
tive effect as oastration. A sufficient clinical material 
has accumulated to prove that these different proced- 
ures frequently result in diminution in the size of the 
prostate and that the symptoms caused by the obstruc- 
tion often diminish or disappear. 
I can readily understand in what manner emascula- 
tion in young animals and young and middle-aged 
men should be followed by atrophy of the healthy 
prostate gland. Castration 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 sub- 
stitutes performed on men advanced in years, with 
atrophic dormant testicles should exert such a posi- 
tive influence upon an organ, the seat of a senile 
affection. And yet, the fact remains that many relia- 
ble 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 misap- 1896.] 
915 
plied 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 differ- 
ential diagnosis betrween simple hypertrophy of the 
prostate and some of the conditions which simulate it 
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 sub- 
jects suffering from obscure affections of the bladder, 
complicating hypertrophy of the prostate gland. The 
Ramm-White 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 legiti- 
mate 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 rea- 
sons 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 indiscriminating surgeons. 
I wish time would permit me to say something of the 
too frequent recourse to the recently revived opera- 
tion of symphyseotomy and the unwarranted proced- 
ure known as Porro’s operation, except in cases in 
which the uterus is the seat of a life-threatening affec- 
tion, some of the evil results following the too fre- 
quent 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 professsion. Let 
us have in the future more of the nil nocere in place 
of the furor operativus. I have written and deliv- 
ered 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 sur- 
gery, and as a plea for recognition of the good work 
done by the great mass and backbone of our profes- 
sion, the modest, toiling, inadequately remunerated 
general practitioner. 
Benefactions to Boston Charities.—By the death of an heir the 
public bequests under the will of Mrs. Josiah Vose, of Boston, 
Mass., became operative and more than $380,000 is released to 
many of the more prominent educational and charitable insti- 
tutions in Boston. These bequests are : Massachusetts Gen- 
eral Hospital, $30,000; McLean Asylum, $30,000; Institute of 
Technology, $25,000; Female Orphan Asylum, $15,000; New 
England Hospital for Women and Children, $25,000 ; Institu- 
tion for the Blind, $10,000; Eye and Ear Infirmary, $15,000, 
and Home for Colored Women, $5,000,