IDEAL SURGERY 
Read before the St. Louis Medical Society. 
BY 
G. WILEY BROOME, M.D., 
PROFESSOR PRINCIPLES OF SURGERY AND CLINICAL SURGERY, WOMAN’S 
MEDICAL COLLEGE; SURGEON TO THE WOMAN’S HOSPITAL; 
CONSULTING SURGEON TO THE ST. LOUIS CITY 
AND FEMALE HOSPITALS, ETC. 
Reprinted from the “Journal of the American Medie!>kAssociation,’' 
February 4, 189:!. »• 
CHICAGO: 
PUBLISHED AT THE OFFICE OF THE ASSOCIATION 
189!!. IDEAL SURGERY. 
Read before the St. Louis Medical Society. 
BY 
G. WILEY BllOOME, M.D., 
PROFESSOR PRINCIPLES OF SURGERY SURGERY, WOMANS 
MEDICAL COLLEGE; SURGEON TO THE WOMAN’S HOSPITAL; 
CONSULTING SURGEON TO THE ST. LOUIS CITY 
AND FEMALE HOSPITALS, ETC. 
.Reprinted from the “Journal of the American Medical Association,” 
February 4,1893. 
CHICAGO: 
PUBLISHED AT THE OFFICE OF THE ASSOCIATION 
1893. IDEAL SURGERY. 
BY G. WILEY BROOME, M.D., 
OF ST. LOUIS, MO, 
Mr. President:—It is plainly apparent to the stu- 
dent of medicine that the practice of modern surgery 
is wholly unlike the practice which prevailed, and 
was approved, only a few years ago. 
In the light of advanced surgical pathology, bacte- 
riology, and the now more familiar processes of 
regeneration and repair, modern surgical methods 
bear but slight resemblance to those that were prac- 
ticed a very short time ago. 
It is furthermore clearly apparent that the whole 
tendency of modern surgery is to secure ideal results, 
and at the same time to keep the practice well abreast 
with the revolution necessitated by the indications 
discovered through intelligent clinical observation, 
scientific investigation and experimental research, 
The scope of this modern ideal surgery—it may 
be emphatically stated at the outset—does not em- 
brace a rule necessitating the adjustment of a class 
of cases to a certain mechanical device, m order to 
secure ideal results; but it does require to act intel- 
ligently and institute such methods of treatment as 
will best serve the purpose in each particular case. 
Modern scientific surgery can only contemplate 
such rules in the light of impediments to its progress, 
as true science is not and never was dogmatical. The 4 
orthodox apparatus must be eliminated from the in- 
strumentarium of the surgeon whose aim is to achieve 
the ideal of liberal scientific surgery. 
I recently heard a distinguished surgeon state in one 
of his lectures, “ that one great hindrance to progress 
is the inexorable penchant of the masses of the pro- 
fession to adapt cases to old established plans of 
treatment. One mounts a hobby and soon others 
follow. Nothing, he thought, could have a more 
pernicious effect upon universal scientific surgical 
advancement.” 
In consequence of the disparity of opinions ex- 
pressed here a few evenings ago in the discussion of 
a report presented by Dr. Outten to this Society, I 
believe that a brief inquiry respecting the present 
status of progressive surgery will not be considered 
untimely or inappropriate. With reference to 
the treatment of compound fractures of the thigh 
No.l 
bone, I wish to reiterate what I then said re- 
specting the use of the Hodgen splint, and which 
was forcibly Illustrated in the case shown here by 
Dr. Outten. The man’s- injured extremity got well, 
it is true, after nearly two years of close confine- 5 
ment; but in consequence of the position in which 
the limb was kept, the knee-joint became perfectly 
stiff and unyielding, with also great angular defor- 
mity at the site of fracture. 
I wish to state here that very soon after I gradu- 
ated in medicine, I was employed as the chief sur- 
geon of the Wabash Railroad Company, and held 
that position during eight years. It was after 
practicing a year or so in this field of surgery, that 
it became painfully apparent to me that the Hodgen 
splint proved to be defective in two essential particu- 
lars, namely : first, that it did not retain the ends of 
the broken bone in apposition; secondly, that by 
applying extension at the foot, and the leg retained 
in a position nearly straight, there wras entailed 
great impairment of the functions of the knee-joint. 
You will bear in mind that Dr. Hodgen himself 
applied his splint to many of my cases, as he, until 
the time of his death, was the chief consulting sur- 
geon at this end of the line of that railroad com- 
pany. The attorneys of that company frequently 
complained that the assessment of damages against 
the company for personal injuries was quite as 
large in consequence of the impaired knee-joint 
(a condition wholly the effect of the splint), as it 
was for the injury itself. Actuated by a sense of 
duty toward my employers, and for the welfare of 
these patients, about this time I devised and made 
this splint which I now showr you. As may be seen, 
my modification of the suspension apparatus is con- 
structed upon the plan of a double incline plane. 
The limb is dressed in a more physiological position— 
that is, semi-flexed, with the extending force fixed in 
front of the knee instead of the foot. By this splint 
the knee-joint is completely protected from over- 
strain and its baneful consequences. You will also 
observe that the splint is so constructed as to enable 
the surgeon to readily adjust it to any sized limb, 6 
including the arm. In adapting the apparatus to 
the suspension of the arm the distal rods must be 
disconnected at the middle joints, the thigh braces 
proper may then be used at once as a complete sus- 
pensory apparatus for a shattered arm. (This is the 
part of the splint used for that purpose.) 
I exhibited the same to Dr. Hodgen, and he ex- 
pressed to me his approval of my modification. I 
continued to use this splint during the years I re- 
mained with the company, and no more complaints 
or excessive demands for compensation were ever 
made from persons with disabled knee-joints after 
the treatment of broken thigh bones. (This device, 
together with an illustration of the splint, were pub- 
lished by Dr. Borck, of this city, in 1879—fourteen 
years ago.) 
Now while this apparatus protects the knee, and 
in that respect it is a great improvement on the 
Hodgen splint, nevertheless it is still defective, and 
does not fully come up to the requirements of ideal 
surgery. But it was one step in that direction. 7 
Modern surgery received its first impulse at the 
time when Virchow published his scientific discovery 
of cellular pathology, in the year 1858. 
The demonstration that cells are derived from pre- 
existing cells came as a revelation to most physicians 
throughout the world. 
The principles of cellular pathology have become 
to such an extent an integral part of medical thought, 
that we can hardly estimate, to-day, all that this 
discovery meant a generation ago. 
To do this we must put ourselves back, in thought, 
to a time when all organized pathological products, 
pus, tubercle, cancer and all tumors, were supposed 
to be formed out of a primitive blastema—an exu- 
dation of some kind. 
Under the influence of such ideas, any coherent 
or intelligent opinion as to the nature and devel- 
opment of morbid processes would be quite impossi- 
ble. The never-ending strife between humoralism 
and solidism would probably be going on to-day had 
it not received its deathblow from cellular pathology. 
The ontological conception of disease processes 
passed out of the horizon of scientific medicine when 
this discovery was made. 
With the recognition of this great discovery, it 
became clearer than ever before, that the laws 
in disease are not different from those in operation 
in health, but are simply subject to different con- 
ditions. 
The second splendid era of scientific value to the 
modern surgeon was inaugurated through the labors 
of the distinguished botanist Schleiden, whose bril- 
liant conclusions, as they were drawn from the study 
of vegetable histology, were at once extended by 
Theodor Schwann to the animal kingdom; and then 
soon followed the demonstration of the migration 
of the leucocytes from the vessels and of the specific 
cellular germs of disease; now the inestimable dis- 8 
covery of W. Fleming designated by the term karyo- 
kinesis, or the indirect mode of cell reproduction, 
was published to the scientific world. 
Out of those researches the function of the cell, 
in the process of regeneration and repair, became 
better understood; and it was soon demonstrated 
that the function of cell life includes, in a condition 
of perfect health in the matured body, the normal 
waste incident to the increasing activity of the tis- 
sues ; and is balanced by the reparative process,while 
during the development of the body, an excess of 
material is added. 
From a surgical aspect, cell reproduction or regen- 
eration observed in the healing of wounds produced 
by severe injuries, and the complete or partial resto- 
ration of parts damaged or destroyed by this, and 
various destructive inflammatory processes caused 
by the presence of specific pathogenic microorgan- 
isms, is a study essential to secure ideal results in 
the practice of surgery. 
There is no doubt existing now in the proposition, 
that an injury, defect, or the loss of considerable 
substance, will be repaired from proliferation of 
preexisting cells, which compose the structure sus- 
taining the injury, defect or loss of substance. The 
fixed tissue-cells at the site of injury being endowed 
from earliest embryonal life with intrinsic power of 
adaptation to existing conditions surrounding them, 
assume active tissue proliferation; and the embry- 
onal cells thus produced constitute the granulation 
tissue, which toward the completion of the healing 
process, is transformed into mature cells, represent- 
ing the injured parent tissues which have undergone 
the reparative process. 
The third era, constituting the simple concep- 
tion, the basis of early antiseptic procedure in 
surgery, that a wound to which bacteria gain access 
becomes infected in the same way that a sterilized 9 
infusion of meat undergoes putrefaction when a 
single suitable germ enters, has, it is true, been 
greatly modified ; but the establishment of this truth 
even before its complete demonstration and the in- 
troduction of wound treatment based upon it, must 
remain forever the merit of the immortal Lister. It 
is the knowledge of the “how” to obtain aseptic 
healing of wounds, that has revolutionized surgical 
practice and made modern idecd surgery possible. 
Soon the fourth era of this brilliant evolution in 
the progressive stages of scientific surgery began 
to take form. It was not long after cell life was 
cleverly understood until Metschnikoff and others, 
by certain methods of scientific investigation, dem- 
onstrated the fact, that the living tissues were not 
passive breeding places for bacteria, but that they 
were able to offer a very considerable resistance to the 
growth of microorganisms. This discovery was a great 
boon to the surgeon, for by it he was emancipated 
from the superstitious dread attending a particular 
surgical procedure where, from unsurmountable cir- 
cumstances, the debridement is unavoidably imper- 
fect and a limited number of bacteria gain access to 
the wound. 
It is owing probably to this fact of phagocytosis 
that many cases of imperfect asepsis in surgical 
operations often heal well. It has been demon- 
strated by Cheyne and others that doses of less than 
18,000,000 of the proteus vulgaris when injected 
into the muscular tissue of a rabbit seldom cause 
any result, and it requires as large a number as 
250,000,000 to produce a circumscribed abscess. 
But of course the condition of the serum, together 
with the macrophagi and microphagi at the point at 
which the organisms are arrested, is also a matter of 
great importance. Tissues which have been dam- 
aged by injury, bad surgery, or defective surgical 
appliances, are not so resistant to the action of bac- 10 
teria as when in a state of health. A healthy peri- 
toneum may receive and absorb a large number of 
bacteria; but if damaged during a laparotomy, so 
that a considerable portion of its absorbing surface 
has been impaired, and at the same time consider- 
able oozing of blood and serum has taken place from 
the injured surfaces, a soil favorable for the growth 
of the organisms is produced and a septic peritonitis 
may result, even though the operative procedure in 
other respects may have been conducted under an 
ordinarily intelligent aseptic detail. Tense sutures 
also are more likely to be followed by stitch abscesses 
than where the suture margins are so coaptated as 
not to destroy the chemotactic properties of the leu- 
cocytes and other elements concerned in phagocy- 
tosis. 
In the light of these discoveries we have learned 
that suppuration means a destructive process, the 
significance, and remote effects of which, can only 
be fully appreciated, by the surgeon, whose best 
efforts are exercised in behalf of humanity, and the 
ideal of scientific work; suppuration itself means 
microbial action upon healthy tissue elements, in 
which leucocytes and embryonal cells are converted into 
pus corpuscles. And it has for some time been known, 
that long continued suppuration of a wound pro- 
duces amyloid degeneration of organs remote from 
the seat of suppuration; that is. by the accumu- 
lation of the ptomaines of pus microbes, coagula- 
tion necrosis may be produced in other organs of 
the body, and amyloid degeneration as a conse- 
quence. 
Hence, after prolonged suppuration the patient can 
never hope to regain his former functional vigor, 
therefore the importance of preventing or arresting 
all suppurative action.. 
Senn long ago made the assertion that pus mi- 
crobes are the immediate and essential cause of sup- 11 
puration, inflammation and pus formation ; and no 
one has as yet been able to successfully contradict 
that assertion. So that the etiological explanation, 
of wound infection, and suppuration, is based wholly, 
upon the presence, and action of the pyogenic bac- 
teria and their ptomaines. 
The chief aim, and object, of ideal surgery, is to 
prevent suppuration, and secure the healing of a 
wound, by the first intention, and without suppura- 
tion. In a wound where there has been so much 
loss of substance, as to prevent a proper approxima- 
tion of the parts, it must of necessity heal by granu- 
lation. In the ideal treatment of wounds, the classi- 
fication into “open” and “subcutaneous” wounds,there 
is no longer the same practical importance, as an open 
wound is at once placed under the same favorable 
conditions for satisfactory and rapid healing, as a 
subcutaneous wound. It was stated here by several 
gentlemen who took part in the discussion of Dr. 
Outten’s paper, that an open wound must be exposed 
to frequent inspection, and that it must also have 
drainage tubes passed through it. 
The fundamental principle underlying ideal wound 
treatment, as I have stated, consists in preventing 
suppuration. To prevent suppuration in an open 
wound, the wound and its environment must be kept 
aseptic. I do not believe that any progressive sur- 
geon will attempt to deny the force and truth of this 
assertion. 
The indications to be met in a compound fracture 
of the thigh, for example, are first, the disinfection 
of the entire wound audits environment; second, the 
approximation of all the structures implicated as 
near as possible to their normal anatomical relations, 
i.e., bone to bone, periosteum to periosteum, muscle 
tendon and nerves to muscle tendon and nerves, skin 
to skin, and direct fixation, over which is applied a 
thick hygroscopic dressing, then immobilization. If 12 
these indications have been completely fulfilled, the 
dressing should not be disturbed for from four to 
five weeks. This is ideal surgery. 
When the profession can realize that fractures 
must be treated in the same manner, as the soft 
parts, in order to secure union by the first intention, 
then and not till then, will humanity have ceased to 
suffer from the surgery of dogmatism. The tradi- 
tional methods, which depend upon provisional cal- 
lus, in the union of a broken bone, have no place in 
modern methods. 
The orthodox apparatus which demands the adjust- 
ment of all cases to any antiquated system, and 
necessarily to defective notions, has been eliminated 
from the instrumentarium of ideal surgery. 
There is no longer any room for argument against 
the danger involved and the unsurgical system of 
treating wounds by the open method. That era be- 
longs to the past and to history, a practice which 
modern surgery looks back upon with horror; a 
wound treated in a manner that constantly exposes 
it to infection, and consequent suppuration and amy- 
loid degeneration of other organs, receives no con- 
sideration from ideal surgery. As to the use of the 
drainage tube, I cannot express my own views more 
forcibly, than in the words of the celebrated surgeon 
and author, Thomas Bryant, of London, who said, “I 
always regret to see a rubber drainage tube passed 
through a wound; it may be through a joint, or 
through a thigh, or stump; such a drainage tube is a 
seton, and is not necessary.” If a drainage tube 
through a wound in the thigh acts like a seton—as 
this distinguished surgeon says it does—then the sur- 
geon who places it there may be held responsible for 
the baneful sequence of long continued suppuration. 
Roswell Park, of Buffalo, who is not only a great 
surgeon but also a pathologist of world-wide fame, 
stated before the congress of American Surgeons two 13 
years ago, “That drainage is mainly practiced from 
habit or from fear. The promiscuous practice of 
drainage is a confession of fear or weakness ; both of 
which are unscientific and unfortunate.” I might 
multiply evidence in this direction, but to an intelli- 
gent body of scientific men it would seem superflu- 
ous. As suggested, when discussing Dr. Outten’s 
case, the favorable progress and termination of such 
a wound, depends almost wholly upon how perfectly 
the wound has been purified and the first dressing ap- 
plied. By “purifying” is meant securing a most thor- 
oughly aseptic condition, by cleansing the entire inte- 
rior of the wound in every nook and recess of possi- 
ble infection; and in order that the wound may be 
rendered perfectly free from microbial contamina- 
tion, it may be necessary, at varied intervals, to 
allow the patient a few whiffs of an anaesthetic, that 
the work may be properly performed without great 
pain. After securing this moderate degree of anaes- 
thesia, the surface of the limb from the abdomen to 
the toes is thoroughly shaved and washed with hot 
water and brush. If grease or other filth of this na- 
ture from machinery is found in the wound, rubbing 
with sweet oil or with turpentine and alcohol before 
scrubbing with soap and water, greatly facilitates 
complete asepticism. Wounded vessels must be 
tied, all parenchymatous oozing stopped, blood clots 
and foreign particles removed, divided muscles, ten- 
dons and nerves sutured, the ends of the fragments 
trimmed, if necessary, and destroyed tissues cut away. 
This work completed, the wound is now thoroughly 
irrigated with hot solutions of first sublimate' and 
then chloride of zinc. The latter penetrates the tis- 
sues and acts as a stimulant to the disabled struc- 
tures ; besides it possesses well known germicidal 
properties. The ends of the broken bone may now 
be approximated and fixed by wire sutures or ivory 
nails or some such device. In the event that there 14 
has been loss of bone substance, Bercher suggests the 
implantation of a solid bone cylinder adequate to 
compensate for the loss. 
Senn, the pioneer of bone surgery, appreciating 
more completely than perhaps many others the 
scientific value of cultivating the implantation of even 
a foreign substance in bone in order to fill up a space 
made vacant by any loss of substance, wires a hollow 
bone cylinder between the ends of the shattered bone, 
thus imitating nature as perfectly as possible ; and the 
healing process proceeds upon the same principle, so 
beautifully illustrated in the healing of wounds, be- 
neath a moist blood clot, first brought into practical 
utility by the renowned Schede. Even though a 
muscle, a nerve, or a tendon, may have sustained a 
considerable loss of substance, by the violence pro- 
ducing a compound fracture, and the ends cannot be 
properly approximated, they must be sutured, just 
the same. Large cat-gut sutures, must be used for 
the purpose, and several sutures introduced; these 
suture strands, will serve as a “false work” over the 
breach, upon which the embryonal cells, may con- 
struct a more substantial bridge, gaining thereby 
almost perfect restitutio in integrum and the attain- 
ment of a perfect functional result will be secured 
in a short time; otherwise the muscle, nerve or ten- 
don having sustained the loss of substance, will 
retract, and their ends heal by granulation and cica- 
trization with almost total loss of functional activ- 
ity, as in Dr. Outten’s case. An efficient external 
support is applied to the thigh and this together with 
the dressings are allowed to remain for several 
weeks. If death of any portion of the injured tissues 
takes place, it will be aseptic death, and no harm 
can follow. Thus, ideal results are achieved, and the 
ideal of scientific progress consummated, and the further 
advance toward that which we should all desire the 
most, namely, the prevention of deformities, the reliej 15 
of suffering humanity, and the prolongation of human 
life and usefulness. 
The special points in the foregoing remarks that I 
wish to emphasize, may be epitomized in the follow- 
ing brief conclusions: 
1. That by the development of cellular pathology 
the process of cell proliferation, and the discovery 
of the laws of repair and regeneration, and the in- 
troduction of Lister’s antiseptic system, the principles 
underlying the practice of surgery have undergone a 
complete revolution within the last few years. 
2. That the principles of scientific surgery are so 
intimately interwoven with the advances in bacteri- 
ological pathology, that a progressive knowledge of 
the latter is essential, in order to be able to intelli- 
gently appreciate its value, in practical surgery, or to 
comprehend the principles upon which ideal surgery 
is founded. 
3. That the observation made by Cabot, “That every 
surgical operation is an experiment in bacteriology,” 
proves to be full of wisdom. 
4. That the merely antiseptic era has been passed 
by modern surgery and the trend of the surgery of 
the future is to purely aseptic procedures; antisep- 
sis is gradually being supplanted by asepsis and dis- 
infection is made unnecessary by avoiding infection. 
5. That to secure ideal results in the treatment of 
compound fractures the injury of the bone must be 
treated upon the same general principles that are 
applied to secure union by the first intention of 
wounds in soft parts; that is, by carrying out in de- 
tail the rules of asepsis and antisepsis, immediate 
and perfect reduction, approximation with direct 
fixation, efficient external support, and immobiliza- 
tion.