THE FUTURE OF SURGERY 
WITHOUT LIMIT. 
BY 
DAVID W. CHEEVER, M.D., 
OF HOSTON, 
I’resident of the American Surgical Association. 
Address 
Delivered at Washington, May 14, 1889. 
BOSTON: 
DAMRELL & UPHAM, 
283 Washington Street. 
1889. THE FUTURE OF SURGERY WITHOUT 
LIMIT. 
BY 1)AVIU W. CHEEVER, M.D , OF BOSTON, 
President of the American Surgical Association. 
Fellows of the American Surgical Associa- 
tion : 
I believe that we are warranted in saying that the 
future of surgery is without limit. I deduce this 
conclusion, first, from considering what the mind of 
man has already done ; second, from the future pos- 
sibilities of fields hitherto unknown and unexplored, 
but now opening up to science. There can be but 
two limitations, either in the mind of man or in the 
subject. 
Since the time when, in the anthropoid, the cere- 
bral lobes first began to creep over and cover the 
cerebellum, what a growth has taken place in the 
penetrating power of the human senses. The brain 
has progressed from the rude hammer of the prog- 
nathous cave dweller to the telescope and the 
microscope. Originally of vision far less acute than 
the eagle’s, the eye of man now ranges from the fixed 
star to the 20,000th of an inch bacteria. We ana- 
lyze the sun’s gases with the spectrum ; we follow 
the magnet unerringly on the sea; we utilize the 
lightning; we count the vibrations of sound; we measure light; we speak across the ocean ; we 
estimate the age of our planet; we analyze atoms ; 
we compose new substances; we make pictures 
from light; we photograph and map the stars ; we 
explore the pole and test the glacial history of the 
world; we find subterranean springs, and light our 
homes from old volcanic sources ; we measure the 
crevasses in the glaciers of Mars; we count tides 
by the moon ; we defy the wind with steam ; we 
foretell storms by the barometer ; we construct iso- 
thermal lines; we inspect the bottom of the sea; 
we demonstrate eclipses ; we measure space by the 
transit of Venus; we predict comets; we find a 
solar and a stellar unit of time ; we unravel Egyp- 
tian chronology; we trace man downward through 
the stages of evolution. Man invents the wheel; 
the ship; the pendulum; the siphon. Under the 
water, in and on the earth; in the air ; in the infinity 
of space; in the infinity of micro-organisms,— the 
mind finds no limit, but is ever restless, ever search- 
ing. And now in medicine averting pestilence ; an- 
nulling pain ; destroying sepsis ; shall we stop ? 
In gradual development the brain of man has 
gone on step by step, investigating itself, until we 
localize disease by the tracings on cerebral surfaces, 
and condense in that wonderful cortical substance 
a palimpsest of impressions, mental and material. 
The brain studies itself. Know thyself,” said the 
Greek; and in searching the crypts of the human 
brain we may well echo the description of the 
greatest of the sons of men, “ How noble in reason! How infinite in faculties! In apprehension, how 
like a God ! ” 
We pass now to the second limitation, in the sub- 
ject itself. Long since was it said that all was 
found out in anatomy, and that surgery had nearly 
reached its limit. Far from this, the microscope 
has created a new anatomy and a new pathology; 
physiology changes yearly; the lower animals 
yield light by the Baconian test of experiment. 
Anaesthesia enlarged surgery ; antisepsis emboldens 
surgery ; and we can set no limits to the advance. 
The three sacred cavities ; the abdomen, which 
means hidden; the thorax, which holds two 
feet of the tripod of life; the skull, which conceals 
the nerve force, the vital principle, all are ex- 
plored. 
Medicine, always obscure, is growing clearer; and 
instruments of precision have been applied to our 
art. The clinical thermometer is the tell-tale of 
internal changes, inflammatory or septic. What 
have we to fear ? We advance haltingly, but we 
advance. 
Specialism exhausts minute localities ; by its 
occasional discoveries enlightens medicine ; by its 
failure calls sometimes a halt. Specialism, tem- 
pered by general medicine, becomes a safe compan- 
ion in our march onward. 
It becomes us soberly to inquire how to study 
the new seats of surgical exploration. What new 
methods are needed ? Where must we be conser- 
vative ? Where can wre be bold ? 4 
Since medicine is composed of a science and an 
art, we must study the science to develop the art. 
The four pure sciences are Anatomy, Physiology, 
Chemistry, Pathology. These purely scientific 
portions of our profession are the only ones that 
can yield positive knowledge, and this only hy 
dissections, experiments, and analyses. 
Modern surgery deals with anatomical regions 
hitherto insufficiently studied. First, the fascia'; 
the linings and bindings of the muscles, vessels, and 
nerves, have great influence in determining the 
course of suppuration and the size and locality of 
abscesses. A perfect dissection and preparation of 
the fasciae does not exist. It is, perhaps, impossi- 
ble to make it. Frozen sections and their photo- 
graphs give the best idea of the relations of the 
fasciae. Familiar instances of the importance of 
the arrangement of the fasciae are to be found in 
the psoas sheath; the saphenous opening; the tri- 
angular ligament of the perineum; the deep cervi- 
cal fascia; the fascia lata; the fascia of the fore- 
arm and the annular ligament; the posterior liga- 
ment or fascia of Winslow in the popliteal space. 
Next, the topographical anatomy of the viscera, 
especially in the abdomen ; not only the variations 
in the reflexion of the peritoneum, but the mobility 
of the organs; the rhythmic changes produced by 
respiration on the veins, on the diaphragm as an 
agent of displacement; and on the pelvic diaphragm, 
the perineum ; the incessant movements of peristal- 
sis and its power to change the locality of organs, —all these have not been sufficiently considered by 
the diagnostician and by the operator. Normal 
splanchnology and frozen sections of the abdominal 
cavity are of more worth to the student than the 
mnemonics of the origin of all the muscles and the 
twigs of all the arteries. The exact relations of the 
mediastina to the oesophagus, aorta, pericardium, 
and pleural cavities are of great importance also. 
No less directly useful is an exhaustive and min- 
ute topography of the brain; the bearings of the falx, 
tentorium, corpus callosum, ventricles, the centre 
of decussating fibres; the ultimate origin of the 
fibres of the cranial nerves; the sinuses; the rela- 
tions of the middle ear; the petrosal sinuses; the 
mastoid cells and their variations; the fissures of 
Sylvius and Rolando. 
When we consider physiology we are struck botli 
by its great progress and by its imperfections. 
The older physiology is obsolete and discarded; but 
in the newer physiology the functions of some large 
and important organs are still undetermined. The 
ductless glands, for instance ; the spleen, the thyroid, 
the thymus, the supra-renal capsules. An ignorance 
of their functions renders the surgeon unable to 
predict the consequences of their removal. Of 
what avail the brilliant operation to excise a double 
goitre, if it is to be followed by an obscure degen- 
eration of the nervous or glandular systems? Again, 
in organs of known function, the limit of the diges- 
tive power of different portions of the alimentary 
canal is not yet definitely learned. How can we 6 
get along without a gall-bladder ? How important 
is the pancreas ? Can the duodenum supplant the 
stomach in nutrition ? How much ileum can be 
removed without starvation ? What will the rectum 
digest ? All these are pertinent questions for the 
physiologist, and have a direct bearing on modern 
surgery. 
In chemistry, the whole study of sepsis, antisep- 
sis, fermentation, germicides, the viability of spores, 
is in its infancy; and as certainly as it already has 
reversed surgical practice, will do so again and 
again. 
The great desideratum of surgery now, if chem- 
istry can supply it, is a new, constant, local anaesthe- 
tic. This would enable us to banish a chief cause of 
secondary shock from our operations. 
Finally, in pathology we have much to learn and 
to influence our surgical practice. Diseased organs 
change appearance and they change place. A 
double puzzle is thus presented to the operator. 
On opening the abdominal cavity we are sometimes 
at a loss to locate an organ ; and even fail to recog- 
nize it, so changed is its look and its 
One part is mistaken for another; a sac for intes- 
tine ; intestine for sac; adhesions for peritoneum ; 
and so in many other instances. It is of the last 
importance that the operating surgeon should be so 
familiar with pathological changes that he can 
distinguish the false from the true at a glance. 
The future destiny of coarse pathological changes 
of organs: whether they are hopelessly diseased; whether they can recover; whether the affection is 
organic or inflammatory; is also to he decided, 
rightly or wrongly, by the surgical expert on a 
brief inspection. 
Having considered how much we may learn or 
hope from the pure sciences, we pass to the other 
limitation of the subject, the arrest or the cure of 
morbid processes. All surgical disease is inflam- 
matory or organic; we must advance by checking 
the inflammatory process, or by preventing morbid 
growths: the first, by averting suppuration; the 
second, by discovering the causes of cell change 
and cell proliferation. Through surgical pathology 
lies the only path. True conservative surgery 
would then be limited to averting the consequences 
of traumatism. The earlier labors of Paget, and 
the later ones of Virchow, Pasteur, and Koch, give us 
some hope of being able to abort suppuration ; to 
inoculate for tubercle; or to eliminate the cancer 
cell. The abortion of inflammation is now much 
advanced by the progressing knowledge of asepsis. 
Pyaemia, the opprobrium of surgery, has been 
enormously reduced in frequency. When suppu- 
ration has occurred, evacuation, drainage, and anti- 
septics have been equally successful in shorten- 
ing the pyogenic process and in promoting repair. 
In tubercle we see the best results follow the 
evidement of Sedillot, both in cancellous bone and 
in suppurating lymphatics. 
As in variola, may we not hope that a modified 
germ may jugulate the tubercle bacillus, by inocu- 8 
lation? or if we meet not the suceess which the 
modification of rabies is slowly attaining, that 
chemistry may give us a reagent to devitalize the 
germ of tuberculosis. 
Cancer, to include under that term all recurrent 
tumors, is, by Virchow’s nomenclature, a misplaced 
cell-growth. Modern research now gives us hope 
of finding the cause of this mal-development; and 
if a germ should be discovered here, a germicide 
will be finally found. 
The manual part of our art, chirurgery—hand- 
craft — requires also to be perfected in connection 
with the advancing boldness witli which we open 
cavities and feel the pulse of life in its central 
shrine. New operations demand a new technique; 
new modes; new instruments; anew code of rules ; 
all to be learned by experiment. Nowhere, per- 
haps, could the French saying, “jevn chirurgien, 
vieux medecin,” be more applicable. It is to the 
young surgeon, born and bred in asepsis, that the 
older physician must look for progress in our art. 
In estimating, then, the limitations of surgery, 
we find none except they be set by ourselves. 
How should they be set ? By conservative judg- 
ment opposed to rashness. In the list of modern 
and useful operations, as distinguished from those 
barely justifiable, are the following: — 
(1) To remove growths or foreign bodies from 
the cavities of the body : opening the brain ; opening 
the spinal cord; displacement of the upper jaw or 
of the nose for naso-pharyngeal polypi; cutting into the pharynx from outside the neek, to remove 
tumors of the tonsil; oesophagotomy for foreign 
bodies; thyrotomy for growths; gastrotomy for 
foreign bodies; opening the gall-bladder for the 
removal of stones; opening the pelvis of the kid- 
ney for calculi; supra-pubic cystotomy for calculi 
and tumors of the bladder; ovariotomy; removal 
of the diseased uterus or its appendages; laparot- 
omy for gun-shot wounds and for extra-uterine 
lactation; excision of the lower part of the rectum 
for growths. 
(2) To reach and evacuate inflammatory pro- 
ducts : opening the chest and resecting the ribs for 
empyaema; opening the abdomen for appendicitis; 
or for chronic peritonitis; opening and drainage of 
pelvic abscesses; of abscess of the vertebrae; 
opening of deep abscess of the neck; evacuation 
of and draining abscesses of joints; peri-nephritic 
abscess and removal of one kidney. 
p3) To relieve obstruction: intubation and trach- 
eotomy ; gastrotomy and enterostomy ; colotomy; 
perineal section; herniotomy. 
(4) To restore continuity: resection and suture 
jof bowel; resection and union of bone; resection 
and reunion of nerves; nerve grafting; reunion of 
tendons and of muscles. 
(5) Unclassified procedures: plastic and osteo- 
plastic surgery ; modifications of orthopedics, in- 
cluding bone sections and excisions; litholap- 
axy; reduction of dislocation of the hip, and of 
the shoulder, by applied anatomy; endoscopy; 10 
rhinoscopy and removal of turbinated outgrowths; 
pathology and removal of adenoids; aseptic wiring 
of fractures ; local anaesthesia in setting fractures; 
closing of skull wounds by the insertion of buttons 
of bone. 
(G) Operations as yet suh judice, or on trial: 
resection of the pylorus; resection of cancerous in- 
testine or omentum ; removal of the spleen; of large 
bronchoceles; of the larynx; the pancreas; the 
prostate gland; the normal ovary; fixation of the 
kidney or of the uterus; puncture of the pericar- 
dium; opening gangrenous abscesses in the lung; 
tapping the ventricles of the brain. 
Hash statements are to be discounted; rash 
operations are to be discouraged. The wisdom of 
our earliest Greek master in analyzing the imper- 
fections of our art holds true to-day: “Ars longa, 
vita brevis est; occasio fugax; experi,entia fallax; 
judicium difficile.” Yet with liaeon came the new 
light of experiment. In his immortal words: 
“ Kecte veritas temporis filia dicitur, non auc- 
toritatis,” Lean not on authority; the test of truth 
is time.