The Monthly Cyclopaedia of Practical Medicine and Universal Medical Journal

ONE of the most surprising things about the present surgical period is the
recrudescence of old ideas which it was fair to suppose had lived their day.
It
assumes a new form and a new direction, but it is easy to recognize the old idea in

THE SURGICAL DISCOUNT OF THE FUTURE.

a thin disguise. The only harm done is that it is a setback to progress. When a theory has lived its day and has not met the inexorable test of time, it ought to be executed and buried without benefit of clergy. That some think they see in this revamped method a new, or a restoration of an old, truth, matters but little, for these are not the men to whom we look for the logical clarity that establishes axiomatic principles, or the final settlement of methods.

This train of thought is suggested by the fact that at the spring meeting of the American Gynecological Society, held at Niagara Falls, a number of Fellows, in the course of a debate, claimed that they never opened the abdomen without removing the appendix, irrespective of the fact whether it was normal or not. One followed the other to claim that this was his routine practice. Strangely enough the size of the town was inversely to the number of his secondary appendectomies, if they may be so termed. As yet no dissenting voice had been raised, but the debate was brought to a ridiculous climax by a guest from a small Western town, carried away with enthusiasm, announcing the fact that he had made fifteen hundred celiotomies, in the course of which he had made thirteen hundred appendectomies. The experience of this young man so far exceeded that of any other operator that it appeared that nothing was left to its advocate to claim.

At the afternoon session several men denounced the method as bad surgery, both in theory and practice. It is doubtful if anything more is ever heard about it in the society.

This idea in the surgery of women is not a new one. Those who are old enough to have been through the stress of gynæcic surgery as it was evolving from its chaotic condition into something like sanity, will recall the line of argument by which the gynecologist of twenty years ago made it appear like malpractice that if you removed one ovary you did not remove the other, lest it also become diseased and the woman made to undergo the hazard of again opening the abdomen. The fear was the danger of opening the abdomen a second time, which transcended the value of a normal ovary.

Fixed delusions die hard. Respect for the sanctity of dry peritoneum was an inherited surgical limitation. It was a guiding instinct twenty years ago, strong enough to overcome the respect due to a normal and important organ. We all know what became of this absurdity. It marks, nevertheless, a shameful chapter in the surgery of women. In the light of this debate in the Gynecological Society, it appears that this idea is yet a factor that shapes the conclusions of some men. The surgical discount of the future, the need of doing something more than one set out to do, lest some imaginary danger may result from it, is the old idea shifted to new fields of surgical exploit.

It is possible that there is, in the case of the appendix, a mixed motive joined

THE SURGICAL DISCOUNT OF THE FUTURE.

to the hereditary respect for the abdominal cavity. This is the very reasonable dread of the enormous fatality attending appendectomy when disease exists in this region of the intestinal tract. If then, the part can be removed when there is nothing the matter with it the surgical future of the individual may be made reasonably sure. It is impossible to predict of any healthy part when, if ever, it will become diseased. To remove it when healthy, simply because its future safety cannot be assured, is both bad and meddlesome surgery. It is not the surgeon's business; if it is, why does he limit his attention to the appendix? The gall-bladder is a frequent offender and ought to be removed for fear of concretions. Why not reinforce suspension of the right kidney by a few extra sutures to meet a possible ptosis of the organ? If the argument is valid it is a manifest neglect of duty to overlook any part which will jeopardize the surgical future of the woman.

Further, if the contention of our over-enterprising colleagues is correct, it is almost painful to reflect upon the advantages enjoyed by women over men from the greater frequency that her abdominal cavity is exploited by the surgeon and the opportunity thus afforded to remove organs which may, in the future, give possible offense. In view of the correctness of this attitude, how fearful and solemn are the responsibilities of those who incline to the opposite conservative contention. He can only point with warning finger to the past and the frequency that surgery of this character has required the rewriting of many chapters full of mischievous

error.

Nothing said here must lead the reader to conclude that the removal of organs which are diseased, or which give a tangible threat of disease, is not a wise surgical proceeding. This is, however, a different matter from the removal of a normal organ which under the law of probabilities may never become diseased. The character of the men who took part in the discussion calls for something more permanent than the few words thrown off in the haste of debate.

This leads up to another phase of modern surgery and one having special reference to gynæcic surgery, namely, multiple operations. If there was any necessity for it, if it conserved any useful purpose which accrued from the women's condition, it could not be criticised, but as a matter of fact logical considerations have nothing to do with it. The sole motive behind the idea is to do all that may be done, or can be done, at one time. Any surgeon who carefully looks after his own patients will have no difficulty in observing the reaction in a patient who has had all the surgery that her nerve centers can sustain and one who could have stood very much more. In one class of gynæcological operations the multiple form is a decided disadvantage. This is in genito-plastic operations. This may be said to be the fine art of surgery. Men who are expert in ablation surgery-the hysterectomist, the öophorectomist, and others of that cult-generally are satisfied in plastic sur

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The Monthly Cyclopaedia of Practical Medicine and Universal ..., Volume 9