The Science of Successful Surgery. BY JOHN B. ROBERTS, PROFESSOR OF ANATOMY AND SURGERY IN THE PHILADELPHIA POLYCLINIC; SURGEON TO ST. MARY’S, TO ST. AGNES’, AND TO THE JEWISH HOSPITAL. The Annual Address of the Philadelphia Academy of Surgery, Reprinted from the “Journal of the American Medical Association,” February 16, 1889. CHICAGO : Printed at the Office of the Association. 1889. THE SCIENCE OF SUCCESSFUL SURGERY. Reprinted from “ The Journal of the American Medical Association,” February 2, 1889. Although I have the honor to appear before you this evening in the role of Orator, and there- by lend my countenance to a time-honored cus- tom, it is not proper to simulate a respect for this useless relic, which I do not feel. The annual address is a most reckless spend- thrift of the time of scientific bodies; equalled in this characteristic by extempore discussions alone. Good scientific work throughout the entire year is better than a long address in January. With such sentiments, Fellows of the Academy, do I to-night enter upon my theme, with little worthy of the telling. “What the subject?” has been a pressing ques- tion. When I was appointed to this duty for 1881, I expected to detail with complaisant text the surgical advances and triumphs of the preced- ing twelve-month; but as you know, at the re- quest of the Academy, I gave place to Professor Gross, the elder, who delivered his historic mono- graph, “John Hunter and his Pupils.” The notes made for that address, seven years ago, would verily seem like echoes from a by- gone generation, so rapidly have the wheels of progress run; and indeed the compendiums, an- nuals and indexes of recent birth cover such ground too thoroughly for me to attempt a single- handed rivalry. I shall, therefore, offer you a few thoughts on 2 the Science or Philosophy of Successful Surgery, in the hope of thereby doing a humble share in advancing the purposes of this Society. True it is that Successful Surgery is the child of those, whose personal labors, fostering devotion and ever watchful eyes have brought it through infantile perils and adolescent temptations to a glorious and noble manhood. I wish, however, to look to night not only up- on the individual traits belonging to these ‘ ‘ Ma- kers of Surgery,” but to those characteristics which have been developed in the life-history of this personified Surgery. Successful Surgery, as an individuality, has definite attributes which those of us who can never be makers of anything, must recognize, lest we retard the growth of sur- gical science and bring obloquy upon our soon-to- be-forgotten names. This art is perennial and will outlive our retrogressive thrusts ; hence to save ourselves, we must, under the goad of keener- brained men, struggle to keep pace with her quick strides. The foundation of much unsuccessful surgery, the cause of much popular distrust in surgical performance, is defective education—whether it be in the collegiate teaching of medical students, in the careless instruction of surgical assistants, or in the improper training of hospital nurses. We are very responsible for such a state of affairs, for there is scarcely a Fellow in this Academy who has not a prominent voice in some school or hospital. Indeed one of the requisites of fellow- ship is the holding of such a position, or in lieu thereof, the performance of valuable scientific work. Why, then, do we not, individually and collectively, have the bravery to insist upon, and the generosity to aid in, the correction of this wrong. Can we claim ignorance of the fact, that in numbers of medical schools, the sole literary 3 requirement of the raw recruit is the possession of a white skin and a male apparel ? Is it news to us that he who knows not the meaning of gyrus and sulcus sits on the same bench with, and listens to the same words as he whose studies have carried him to the surgical intricacies of cerebral localization ? What hope is there for successful surgery while good men abet such anomalies by accepting re- sponsible posts as teachers in such false temples of learning ! What success can we expect from the pupil who sees his masters such embodiments of false logic ! Again, how can the student learn surgery without anatomy ? How can he learn anatomy without facilities for examining museum specimens and for making dissections, without instruction in the anatomical and surgical land- marks of his own ever-present body ? Are not cadavera largely wasted by the pupil who dissects in an anatomical room destitute of skeleton and blackboard and guiltless of the presence of cathe- ter, bellows, or even tanks for washing viscera ? Does any student of medicine ever study the dis- sected body in the erect posture? How slow must be the march of improvement, until each and every guilty school is proscribed, and the mutilated and maltreated public protected by the State assuming the power of examination and li- cense ! How like these days to those in which Hippocrates found the ignorant physician suffer- ing no punishment but disgrace, which it was truly said galled not him familiar with it! Very faulty also is the surgical instruction ob- tained by the internes of many hospitals. Fortu- nate above their brethren who receive no such appointments, but yet unlucky too, if compelled to serve under careless, hurried, or ignorant chiefs ! Unsuccessful surgery of after years is often due to imitation, perhaps unconscious, of 4 the faults of a long-dead hospital superior. It is the unwritten duty of the chief to aid in the per- petuation of good surgery by an example of accu- rate, painstaking and therefore successful work. If he have not time or ability to thus aid patient and pupil, whose interests are truly one, let him step aside for another. The hospital of to-day has no need of the surgical figure-head, however great his name; no room for the bungler, who sacrifices life ahd prostitutes the high calling of surgeon by inoculating his patients by means of dirty fingers and soiled linen. An evil influence is exerted also by the selfish hospital surgeon who never permits his junior to do major operations. An intelligent interne gives his time to the hospital, that he may learn. It is, therefore, the chief’s duty to give him an oppor- tunity to operate, under the chief’s direct per- sonal supervision, be it understood, when the pa- tient’s safety and the hospital’s rules and interests do not contravene. In homicide cases, in opera- tions whose expediency has not been fixed by general consent, in procedures requiring the well- trained educated touch, such deputizing is not permissible ; but we all know that a resident sur- geon can justly undertake amputations and many other operations, if we supply the experienced judgment, and guide the successive steps of the mechanical performance. A little less selfishness, a little more generosity on the part of attending surgeons would increase the world’s youthful supply of successful operators. Much otherwise successful work is vitiated by carelessly selected assistants. An assistant who does not know the danger of anaesthesia had bet- ter be relegated to the practice of cheiropedy ; and especially so, if in addition he be ignorant of the fact that suppuration in an operation-wound is usually the fault of the surgical handiwork. 5 It has been said that the lucky are never the lazy or incompetent; the unlucky never the val- iant or wise. The successful surgeon is largely so by virtue of his own inherent fibre; and the personal equation is a factor deserving considera- tion in surgical, as in astronomical problems. The surgeon to attain success must above all things be a man of executive ability and manual dexterity ; but to these he must add that care, in details of operations and after treatment, as will prevent the unexpected from defeating the object of his well-planned and well executed handiwork. Absence of executive ability is as conspicuous among those holding surgical posts, as it is in those occupying other positions of trust, A mer- chant, with too large a contract for his feeble ex- ecutive grasp, is certainly less ludicrous and pitia- ble than the surgeon, whose constant appeal for suggestions and whose frequent operative vacilla- tions show that he had no well defined procedure in mind when he made his initial incision. Un- expected difficulties, unforseeable complications may require operative change, and true regard for the patient may demand professional consulta- tion with the by-standers ; but this truth does not condone the fault of a scatter-brained opera- tor, who knows neither what he intends to do, what he wants to do, nor what he ought to do. He i$ worse than the tyro who shuts his eyes and leaps aside at the first arterial spurt, instead of thrusting his finger tip against the offending ves- sel’s mouth. Manual dexterity, though inherent in some, may be acquired by most of us, if its seeds are nourished in life. Give the embryo surgeon a kit of tools, a jig-saw and a lathe ; or let him work in the sooty forge of the neighboring black- smith shop, as did Joseph Pancoast, and you will either develop his sleeping manual skill or prove 6 before college days his inaptitude for a surgeon’s work. Can you expect any medical school to make a surgeon of a man who cannot tie a dextrous knot, point a lead pencil, or sharpen a jack-knife ? The practice of ophthalmology, otology, laryn- gology and gynecology, conduce greatly to the manipulative skill of a surgeon. The delicate touching and the Lilliputian instruments re- quired in cataract extraction, for example, well train the hand for a neat carotid ligation, a suc- cessful tracheotomy, or an artistic trephining. Besides that it puts the surgeon in possession of instruments better suited to perform such deeds than the clumsy tools of the ordinary operating case. He is not likely then to select a sword-like scalpel for an amputation, more neatly done with a three inch bistoury, In my own surgical work I find my cataract knife a constant companion ; and rarely do an operation without the aid of strabismus forceps. It must be observed too, that in these qualities of executive capacity and manual skill, there is no aristocracy of talent. The surgeon, as the poet, must be born, not made ; but he need not be born of chirurgical parentage, or even in a surgi- cal atmosphere. I have seen the best surgical work done by young men, who have had no special surgical opportunities in birth, friendship, or education ; while the worst may be seen at the hands of others blessed with every facility of in- struction, observation and experience. Let not the experienced operator, whose well- trained hand obeys with seeming recklessness the decisions of his rapid brain, despise, however, the painstaking care of his less dexterops brother. Genius, we are told, is eternal patience, and the fearless accuracy of the skillful is the reward of well-spent hours. A brilliant operator without caution and care 7 becomes the unsafe surgeon, whose skill leads to excesses which his lack of care makes unwarrant- able. “Chirzirgus mente priiis et oculis agat quam manu armataI have no respect for the sur- geon who cares more for the number and novelty of his operations than for the welfare of his pa- tients. A record-making surgeon is to be avoided. A little caution would diminish the number of hysterectomies of wombs containing living foetuses, and show us fewer incisions of the pregnant uterus for ovarian cysts ! So, care in detail will counter-balance much inferior opera- tive work. Above all, the successful surgeon is a man of action. Experience and knowledge must be there, but they are of little value without action. Inexperience and ignorance are the parents of timidity and recklessness. To avoid these dan- gers he must have experience and knowledge, which though power, are mere possibilities until used as a source of deeds. The victory of battle is to the leader who does most, not to him who knows most. The true surgeon often takes the offensive, which is for the intrepid alone ; but the weak surgeon falters and lets death come because of his offensive hesitency. The requirements of aggressive surgery demand a form of inherent moral power absent in many individuals, though, perhaps, replaced by gentler and more lovable qualities. Self-reliance must make the aspirant for surgical honors equal to all his opportunities, for it has been well said that self-trust is the first step to success. He also needs the qualities of that hero in romance who had ‘ ‘ the energy of silence, of patience, of the profound strategy which lies in unswerving persistence,” A knowledge of the collateral branches of medi- cine seems more essential to good surgery than does an acquaintance with surgery to successful 8 medicine. A good physician—I mean a special- ist in medical practice—may be almost ignorant of the principles of surgery ; but success cannot attend the mere mechanical operator, who knows not the signs of a pyothorax, the clinical and microscopical symptoms of a waxy kidney, or the temperature record of a septic fever. A professional career may be blasted, too, by the work of a jaded and over-worked body. Sur- gery requires an alert brain, a quick eye, a steady hand, a clear judgment; all absent when the machine is habitually worked beyond its limit of endurance. The causation of many inexplicable historical and political problems may be found in the bodily health of some actor involved ; and so, the bodily functions of the surgeon are responsi- ble for many of his acts and “ mis-acts.” It may seem an invidious comparison to say that the surgeon suffers more thus, than the physician ; but is not the instant responsibility, often thrown upon him, harder to bear than the less sudden emergencies of the physician’s life ? The de- mand for immediate action based upon knowl- edge, uncalled-for during many previous years, is often appalling to the conscientious surgeon. “Semper paratus"—to be always ready—means incessant anatomical and surgical toil. No time to consult digest, lexicon or text-book is given to him who practices emergency surgery. The present exigency often demands instant action without needful instruments and without profes- sional advice. In this respect city surgeons are so fortunately situated, that they often lack the inventive reliance of their country brothers. The latter will make a female catheter of a pipe stem, goose quill, or a straw, or vaccinate a baby with a needle point, while the former sits regretting the absence of pocket-case and lancet. Again, the brilliancy of a possible success may 9 be dimmed by the surgeon’s desire to show the prospective patient the exact degree of danger in- curred in an impending operation. Indeed it is possible that some of us may be over-zealous in showing the disadvantages and dangers of opera- tion in otherwise hopeless cases. The laity can- not see, under such circumstances, the future horrors of a prolonged life : and how far the present risks are to be assumed should, perhaps, be decided by the surgeon. This is, to my mind, one of the most wearing responsibilities of surgi- cal life. When to urge and how strongly to urge operative procedures are often harassing conun- drums. While thoroughly willing to undertake the most desperate operation, the surgeon finds a severe mental strain in the conscientious endeavor not to unduly encourage the assumption of such risks, and at the same time to give all that sur- gical science makes available for human suffering. The proper decision of this question has a direct influence upon personal and scientific success. Rashness and importunity in advising operations are always to be deprecated. The true surgeon never wants to operate, but is always ready when operation is justifiable. A mere cutter is neither a surgeon nor a humanitarian. The successful surgeon is he of a discontented spirit; who courts criticism and fears it not; who criticises himself as cruelly as he judges others ; who reviews his own deeds with a keen eye, with no tolerance for the bungler because he must say “homo sum'' He has opportunity to see errors in his own work invisible to any looker-on. Ret him search these with careful scrutiny, not covering them with self-complacency. It is said that the wound of a friend is sweeter than the kiss of an enemy; hence, one can well afford to hurt his own self-esteem, since success attends such suicidal policy. Open to conviction must he be, not disdaining to learn from his superiors even if they be his rivals or his juniors. The ungenerous rejection of such knowledge and instruction argues self-conscious inferiority, or at least the absence of the security of conscious power. That the sun fears not the rival light of the new-born moon should be remembered both by institutions and individuals. An important adjuvant to success in operative surgery is rapidity of action without flurry. “ Ohne Hast, ohne Rast,” the poet-philosopher’s dictum well applies to surgery. Nimble brains and fingers are the surgeon’s best equipment for operative perfection and success. To occupy five seconds in opening a felon, without anaesthesia, when two seconds is sufficient, is butchery. The witless apprentice knows that you can drive a nail effectively with a quick blow, while many times the power slowly applied is ineffectual. Surgery shows similar illustrations of the ad- vantage of celerity. Want of this surgical alacrity is painfully evident even in those com- ing to post-graduate schools after years of pro- fessional practice. To be sure it is partly inex- perience and ignorance, but much of it is mental lethargy. Such men are not fitted for surgeons. The general standard of surgical excellence is lowered, in my opinion, by the unwarrantably high fees exacted at times by recognized leaders. Such fees compel the public to accept inefficient, though cheaper service, with a corresponding depreciation in the reality of surgical success ; and at the same time indicate a failure on the surgeon’s part to recognize the humanitarian side of professional life. No just man will charge more than his services are worth, because the pa- tient is rich, any more than he will pay a pecuni- ary commission for consultation practice brought to his door. 11 What are the characteristic attributes of the personified Surgery of to-day, which make it in the eyes of the world almost an exact science; certainly thus exceeding its sister, Medicine. Simplicity, accuracy, and certainty are the tripod upon which has been reared a wonderful structure of successful progress and aggression. Its simplicity resides in its methods as well as its instruments. Contrast the simple and un- varying dressings, applicable to dissimilar condi- tions, of modem aseptic surgery with the former multitudinous formulae, varying with the location of disease and the caprice of the individual surgeon. Then, each surgical condition had its specific application, and each surgeon his opinion as to the best application for such condition. Now, though there be preferences as to thera- peutic means, the number of admissable formulae is small; and personal deferentiation made for varying conditions almost unknown. The sim- plicity and uniformity of pharmaceutical prepara- tions for internal medication would be incredible to the chirurgical polypharmacist of the last century. Absence of surgical complication and our ac- curate knowledge of physiological therapeusis have now reduced the surgeon’s needs in this direction to a ludicrous minimum. A few ounces of ether, a few grains of corrosive sublimate or hydronaphthol, a few strands of catgut, plenty of boiling water and a piece of soap, constitute the pharmaceutical essentials of an extensive opera- tion ; and many surgeons do perfect work with- out the mercury or naphthol. This seems, in- deed, a travesty of the outfit of Ambroise Pare or Baron Larrey. Thus also is simplicity apparent in the con- struction of instrument and apparatus. Mechan- ical complication may be permitted, is, in fact, necessary to accurate performance, in wood and 12 metal, but it cannot replace manual dexterity in operations upon the changing and ever-varying living body. The attempt to substitute me- chanical complexity for surgical skill, in opera- tive methods and surgical appliances, dwarfs the surgeon’s mental and manual development, in- creases the liability to mishap, and defeats his object, the best manipulative service to the dis- eased or injured patient. I would not be understood to underrate the im- portance of properly made instruments or the dis- advantage of inefficient ones. A poor workman is said to find fault with his tools. The counter- part is equally true, that a good surgeon never has poor tools. And yet, has any one of you ever had a trephine re-sharpened after successive operations have blunted its virgin teeth ? Have you not often accepted from your instrument maker a gnawing forceps without a keen edge ? Do you not know that chisels and scissors are proverbially as dull as a Boeotian shepherd ? Such negligence, however, is venial; but a gimcrack lithotome or a safe-cutting skull per- forator, warranted not to do harm in the clumsi- est fingers, is a complicated abomination, deserv- ing the reprobation of every surgeon who knows the location of the bladder and who has been taught to make an incision. A skillful surgeon is known by his deft fingers and few tools. To be equally deprecated is the manufacture of retro- flexed, anteverted, doubly-twisted, and otherwise specially moulded splints, guaranteed to over- come muscular displacement that never occurs, or named after men who never recommend them. Such measures to replace the surgeon’s brains by specially labeled appliances to suit every condi- tion, is a plagiarism of the homoeopathic globule- case with its numerical antidote to every human ill. 13 Complexity is allowable only when skill and simplicity fail to accomplish the necessary pur- pose. Permanent traction with adhesive plaster has succeeded the Desault splint for treating frac- tures of the femur. Eet similar simplicity as successfully reign in all departments ! The revolution has more than begun. May it be completed by American surgeons rejecting still other legacies of European combersomeness ! Accuracy is another factor of extreme im- portance in the evolution of successful surgery. The ‘ ‘ rule of thumb ’ ’ may be allowable in the culinary department of the household, but not in the diet-kitchen of the hospital, nor in the dosage or operative work of the surgeon. Surgeons are especially inaccurate in their pathological knowledge, and this alone has added many unsuccessful cases to surgical history. Ac- curate pathological study, accurate and discrim- inating diagnoses, accurate and perfect operating, done with a hand that never trembles and a heart that never quails, will give us success to rival that already obtained in these marvelous latter days. This admirable state of science, however, cannot be reached, while professors affirm to their classes, that excised portions of nerve are en- larged or inflamed, when they themselves know nothing of its usual appearance except as seen in the shrunken indurated cadaver; while men persist in operating upon what they call “Empyemm,” or prescribe doses of that non-existent remedy “Sulphate of Cincho«