SOME OBSERVATIONS 
The of preventive pnrgerij, 
BY E. J. WARD A. M., M. D., 
WAXAHACHIE, TEXAS. 
[Reprint from Daniel s Texas Medical Journal J SOME OBSERVATIONS 
ON THE 
Possibilities of Preventive Surgery. 
BY E. J. WARD, A. M., M. D., WAXAHACHIE, TEXAS. 
[Read at the Twenty-first Annual Convention Texas State Medical Associa- 
tion, at San Antonio, April, 1889.] 
TN AkL civilized nations the preservation of human life is justly 
regarded as the first and highest duty of the State, and 
though imperfect and inadequate as are the means employed to 
this end, indeed must necessarily be, in the present chaotic state 
of our knowledge, not only of the nature and cause of dis- 
ease, but of the subtle and intricate machinery of our being still 
with each decade there is an appreciable advance in the develop- 
ment of means for the conservation of life, the preservation of 
health, and the prevention of disease. 
In one way or other almost every department of knowledge 
has been made tributary to the maintenance of health and the 
prolongation of life; and hence, notwithstanding the many addi- 
tional dangers, which menace life through the constantly increas- 
ing artificial habits of the people; the multiplication of accidents 
which inevitably attend the growing facilities for rapid locomo- 4 
tion; the sacrifice of human life by the improved engines of war, 
and the lengthening of the death-roll by the compounding of in- 
herited disease, the vital statistician is enabled to give to the man 
of to-day the cheering intelligence that ‘'the days of his years” 
are noticeably lengthening. 
When Henry and Morse were'engaged in their toilsome ex- 
periments in telegraphy, they little dreamed that they were 
opening up an avenue through which the important science of 
meteorology was to be developed, a science which to-day com- 
pels the storms, so destructive to human life upon land and sea, 
to yield up the secrets of their genesis and in some measure, at 
least, rob them of their life-destroying power. 
The early opticians could have had no conception, no matter 
how prophetic may have been their pre-vision, of the revelations 
their optical devices were destined to make, of the stupendous 
influence the microscope would some day exert upon therapeu- 
tics and preventive medicine. 
Nor could the men who in days past, laid the foundation of 
the now magnificent pile to which we give the name biology, 
have had the faintest glimpse of the splendid discoveries of Pas- 
teur and Koch. Doubtless they were as far from foreseeing these 
important achievements, as we of to-day are from estimating the 
practical results that may flow from them in the future, results it 
may be, that will open the way for the complete suppression of 
many or most of the diseases which now swell our mortuary re- 
ports. Already preventive medicine has done much to retard 
the march of disease, and to diminish the fatality of many of 
those which it fails to prevent. 
All sciences must pass through certain stages before any use- 
ful application of them can be made. First, a great many facts 
must be collected, and these must be arranged before the stage of 
induction is reached, while the highest attainable stage, the deduc- 
tive, is a still later achievement. In preventive medicine the 
collection and arrangement of facts necessary to serve as a basis 
for induction, is attended with the rarest difficulties, requiring a 
vast amount of technical knowledge, covering almost the whole 5 
field of scientific research. Hence, progress is necessarily slow 
In preventive surgery, of which it is nay purpose to speak to 
you to-day, little or nothing has been done even in the prelimi- 
nary stage. Is there nothing to do in this field? It seems to me 
that “the harvest truly is great, but the laborers are few.” 
That the various forms of cancer are alarmingly increasing; 
that uterine displacements now more than ever before menace 
the health and happiness of our women; that there is a larger 
percentage of sufferers from hernia now than in any preceding- 
age of the world, and that many other surgical diseases are steadily 
gaining upon our race, cannot be doubted. The reasons for the 
increase of these affections are not far to seek. 
, In order to confine this paper to the limits which this Associa- 
tion in its wisdom has set, I must needs eliminate from the dis- 
cussion several surgical diseases which it would be desirable to 
consider, and the few I shall be able to bring under your notice 
in the time allotted to me, must be treated with a brevity not 
consistent with that clearness which should characterize a paper 
presented for the consideration of so learned a body as the one I 
have the honor of addressing to-day. 
It is essential to this discussion that I should direct your atten- 
tion to some of the general facts of Organic Evolution, and later 
it will be necessary to consider very briefly, but with more par- 
ticularity, one of the factors by which evolution of the organic 
world has been brought about, viz: the inheritance of function- 
ally-produced modifications. 
We find a large number of women, a vast number it must be 
regretfully admitted, who are suffering from some of the forms of 
uterine displacement. Why is this ? Manifestly it is because 
the uterine ligaments and vagina are inadequate to sustain the or- 
gan in its proper pelvic position. But why this insufficiency ot 
uterine support? To this question a majority of gynecologists 
will answer: “Artificial modes of life have impaired the strength 
of the ligamentous supports, which in women of normal health 
and whose functions are performed naturally, are ample to main- 
tain the uterus in place.” 6 
We think the answer contains a two-fold fallacy. It is no 
doubt true that the artificial habits of women, especially those 
which tend to impairment of muscular tone, predispose to dis- 
placements, but the answer is only true to this extent. We shall 
maintain that the uterine supports of woman are naturally in- 
sufficient to maintain the womb, under all conditions, in its 
proper pelvic plane since the woman has attained the upright 
position. Hence, that the uterus of woman is naturally prone 
to displacement, and that the most perfect woman (I do not 
say the ideal woman) physically considered, is liable, under un- 
due exertion or other slight cause, to malposition of the womb, 
and that the modifications resulting from the aberrations of function 
which accompany and are inseparable from these displacements, 
are transmitted to offspring. This we believe, affords the true 
explanation of the prevalence of uterine disorders in women, and 
at the same time suggests the means by which they may in the 
future be overcome. There can be no doubt that the inherited 
tendency to falling of the womb is in some degree offset by that 
other important factor of organic evolution, natural selection, or 
the survival of the fittest. But we have no means of estimating 
to what extent the latter factor may modify the inherited predis- 
position to uterine displacements. Among savages, especially 
those of nomadic habits, and those among whom woman is the 
bread winner, it no doubt plays a somewhat important role; but 
among civilized women, whose modes of life are such as to en- 
able them to endure these ailments, aided by the skill of the gyne- 
cologist, its influence must be very inconsiderable indeed. The 
latter are often enabled to struggle through the whole or part of 
the child-bearing period, and thus transmit to their offspring 
their own unfortunate weaknesses. 
Cervical lacerations, especially those which retard or prevent 
involution, favor, among other evil consequences, uterine dis- 
placement. This will, of course, be admitted by all gynecolo- 
gists; but we shall go a step further, and say that the alterations 
of function, born of these displacements, result in the acquire- 
ment of modifications, which are inheritable. The evidence re- 7 
lied upon to support this conclusion, will be briefly discussed 
further on. 
Tet us now turn our attention for a few moments to hernia, 
and for the sake of convenience, we will limit our inquiries to in- 
guinal hernia. Here, as in the case of the uterus in woman, we 
shall maintain that it is perfectly obvious that, in respect of his 
inguinal canal, man is ill fitted for the vertical position. There 
is certainly no proper adjustment of this part of his anatomy to 
the position he has assumed as the “lord of creation.” The 
most perfect man, who to-day walks the earth, is not secure from 
rupture. An imperfectly closed abdominal ring constantly in- 
vites a knuckle of intestine to enter—a sort of “will you walk 
into my parlor, said the spider to the fly, ’ ’ invitation—which is, 
alas, too often accepted—how often, the heaps of trusses, which 
greet the eye in every drug store and surgical instrument shop, 
bear melancholy witness. 
Whence all these hernias? Here again the surgeon answers, 
“Artificial life, predisposing to hernia,” and again we reply, this 
is only true in part. 
But the objector will say that the savage is but rarely a suf- 
ferer from hernia. This is true, and for substantially the same 
reasons that savage women infrequently have uterine prolapse. 
If a hernia develop in the savage, he has no adequate means 
of keeping the gut in place, hence strangulation and death are 
almost inevitable, while the more favored survive to beget off- 
spring in whom there is no hereditary predisposition to hernia, 
beyond the natural susceptibility already pointed out as common 
to all men, as at» present constituted. 
What surgeon has failed to recognize the traces of heredity in 
studying the etiology of varicocele? What anatomist has not 
been impressed with the anatomical incongruity of the vascular 
apparatus concerned in varicocele, with the erect posture of man? 
The vast majority of sufferers from this affection who apply to 
the surgeon for relief, are persons whose vocations render neces- 
sary the upright posture, a fact which would seem to negative 
the theory of Gould, that varicocele is due to venous hypertro- 8 
phy, resulting from the transference, at puberty, of stimuli from 
the testicle to the veins. If this were true, varicocele would be 
as likely to occur in persons of one vocation as another, and 
would show no preference for one side more than another; where- 
as the fact is, that in immensely the larger number of instances 
it occurs upon the left side. 
For want of space I must resist the allurements to discuss the 
bearings of these facts upon the phylogeny of man, and content 
myself with merely calling your attention to the significance of 
the anatomical peculiarities of the left spermatic vein. When 
we take into consideration the length of this vessel, the angle it 
makes to empty its contents into the renal vein, the obstruction 
it meets with from the sigmoid flexure and the inadequacy of its 
valvular safeguards, it is certainly not difficult to see why dila- 
tation of the spermatic plexus should occur even in the most 
perfect man. Nor is it a matter for surprise that varicocele, thus 
produced, should give rise to such modifications of function as 
would beget in offspring a tendency to varicocele. 
Now, before discussing the question of preventive surgery, as 
applied to the surgical affections I have designated, it will be 
convenient, if not necessary, to consider, in the briefest manner 
possible, some of the facts upon which biologists rely as evidence 
that functionally-acquired modifications are inheritable. 
It is well known to every one who is at all familiar with bio- 
logical literature, that Lamarck and Erasmus Darwin regarded 
this factor as perhaps the sole agency in the evolution of the 
organic world, but it remained for Charles Darwin to make clear 
the stupendous importance of natural selection as an evolutional 
factor. Since then, the overshadowing importance of this factor 
has so obscured the one proposed by the elder Darwin, that the 
latter was, for a time, almost ignored; not, nowever, by Charles 
Darwin himself. It is probable, however, that every biologist of 
the present day admits the importance and necessity of this factor 
in organic evolution. 
It would seem quite impossible to account for the small size of 
the jaws of civilized man, as compared with those of his remote 9 
ancestors, in any other way than by the hypothesis of the hered- 
itary acquirement of modifications which were wrought through 
the partial disuse of the jaws in the eating of food so prepared as 
to reduce the effort of mastication to the minimum. Certainly 
the attenuation of the jaws in no wray specially fits man to strug- 
gle against his environment; hence, we may eliminate what Mr. 
Herbert Spenser calls the survival of the fittest, as a factor in 
bringing about such attenuation, and sexual selection may, for 
reasons that are sufficiently obvious, be left out of consideration. 
In dogs which have been bred as household pets, as the pug, 
the diminution in the size of the jaws and the attenuation of the 
muscles of mastication are so pronounced and significant as to 
leave no doubt that dainty feeding and consequent functual inac- 
tivity of the jaws afford the only reasonable explanation of the 
phenomenon. And if the changes thus wrought accumulate, 
generation after generation, as it is perfectly evident they do, it 
is certainly inferable that the inheritance of functionally-acquired 
modifications is the channel through which they are brought 
about. 
The disappearance of the sesamoid bones in the hands and 
feet of the white man, which still exist in the negro, would ap- 
parently be inexplicable upon the hypothesis of natural or sexual 
selection. The disappearance of these bones, which are but 
vestiges of man’s arboreal life in the remote past, from the hands 
and feet, cannot in any way enhance the chances of the white 
man for survival, and no reasonable explanation of their absence 
seems possible other than that functional inactivity of these 
bones, consequent upon the abandonment of arboreal habits, has 
resulted in their modification, and that the accumulation of these 
modifications through heredity has eventuated in their oblitera- 
tion. The sesamoid bones here alluded to are exceptionally 
found in the white man, while they are uniformly present in the 
negro. In my own dissections I have never found them in the 
white man, except upon the thumbs and great toes, where they 
are always present, nor have they ever been absent from any of 
the fingers and toes of the negro. 10 
The evolution of the race horse affords striking and seemingly 
irrefutable evidence of the transmission of functionally acquired 
modifications. The careful and persistent training of the racer 
tends to develop every organ and muscle necessary to rapid loco- 
motion, and the structural modification which this functional 
discipline begets, is transmitted from sire and dam to offspring. 
The history of the running and trotting horse bears ample 
witness of the truth of this conclusion. 
The pointer pup is without difficulty taught to point the game, 
and the young setter needs little or no training to teach him to 
set. The bull dog could not in a life time be trained to do either. 
The conclusion seems to be inevitable that the structural and 
other changes resulting from training, have, from generation to 
generation, been transmitted in constantly increasing increments, 
until the evolution of these various types was effected. 
The hereditary acquirement of insanity admits of no reason- 
able doubt. Examination of the brains of certain insane per- 
sons shows a marked derangement of the cerebral blood vessels. 
In some instances it has been found that the posterior lacerated 
foramen was so contracted as to impede the exit of blood from 
the brain by way of the jugular vein, and also that pronounced 
pathalogical changes had taken place in the choroid plexus. 
These facts are full of suggestions to the biologist and clinician. 
Moxon some years ago called attention to the probable influence 
of the choroid plexus in maintaining intra-cranial blood vascular 
equilibrium. These finger-like processes l}’ing in contact with 
the tensely stretched pneumogastrics, become filled with blood 
when we lie down or stoop, and thus exert sufficient pressure 
upon the vagi to slow the cardiac revolutions, and in this way 
lessen the arterial blood supply to the brain. And as I pointed 
out a few years ago in a paper read before the Ellis County Med- 
ical Society, a similar influence would be exerted upon the pneu- 
mogastrics in their passage through their foramen lacerum pos- 
terius, by the accumulation of blood in the gulph of the jugular 
vein. It is easy to see how a pathalogical condition of these 
parts would affect a blood supply to the brain and bring about 
disturbance of cerebral function. 11 
One has only to consider the many means devised by nature, 
to maintain equability of pressure within the cranium to appre- 
ciate the dangers of fluctuation in the cerebral blood streams, 
for in addition to the admirably adapted automatic apparatus 
just mentioned, every anatomist has been struck with admiration 
by the tortuous course of the internal carotid and vertebral arte- 
ries, which protect the brain from the shock of the ventricular 
impulses; the unique arrangement of the cerebral veins and 
sinuses, which form a quasi overflow; the ebb and flow of the 
cerebro-spinal fluid, and the intricate and ever alert vaso-neuro- 
mechanism, all working in harmony to maintain the integrity of 
the great nerve centre, and wThich, though admittedly inadequate 
to maintain under all circumstances that nicety of adjustment 
which the extreme delicacy of the brain demands for the per- 
formance of its highest functions, yet serve to meet the ordinary 
requirements of the brain in health. When we contemplate 
these varied and complex safeguards to the cerebral circulation, 
in ceaseless operation, to protect the brain from injury and en- 
able it to perform its marvelous functions, it becomes apparent 
that anything which throws this intricate machinery out of gear, 
must result in circulatory disturbances and consequent aberra- 
tions of cerebral function. That functional perturbations of the 
cerebrum arising from this cause, eventuate in insanity, will 
probably not be questioned. And that insanity, thus acquired, 
is inheritable, rests upon as high a degree of probability as does 
the inheritability of any other form of insanity, and indeed, 
while perhaps not so clearly demonstrated, is no less certain than 
the hereditary transmission of syphilis. 
It is not the purpose of this paper to discuss “Evolution,” but 
merely to bring under your notice one of the factors of the won- 
derful process by which has been evolved the varied and ever- 
varying Flora and Fauna, wrhich to-day excite our wonder and 
challenge our admiration. This one factor has been discussed 
only in so far as seemed necessary to the elucidation of the sub- 
ject under consideration. 
It will suffice, for the purposes of this paper, if wre have shown 12 
that use tends to strengthen and develop certain parts, as the 
parts concerned in the locomotion of the race horse, and that dis- 
use diminishes or obliterates them, as in the case of the blind 
crabs in the Mammoth Cave, in which the eye stalks still remain, 
or that of the sesamoid bones in the Caucasian, already alluded 
to, and that modifications thus acquired are transmitted to off- 
spring. For if such modifications do occur, and are inherit- 
able, it is justly inferable that modifications produced by other, 
and perhaps less obvious functional perturbations, are also inher- 
itable. 
Now let us take the case of a female who is suffering from 
those distressing nervous affections consequent upon perverted 
ovarian function, such as called into play the genius and skill of 
Battey. 
Now, if the modifications arising from such functional excita- 
tion are inherited, and that they are, rests upon evidence that 
leaves no room for doubt, is not the importance and value of 
Battey’s operation to the individual upon whom it is performed 
overshadowed by its importance to the State? In other words, 
is not the operation of Battey, while eminently justifiable in 
what it accomplishes for the individual operated upon, to be 
measured rather by what it prevents, than by what it cures? It 
It would seem that every student of State medicine must an- 
swer, yes. 
What sadder spectacle can the student of sociology contem- 
plate than the multiplication of offspring in whom are being 
compounded the miseries of an ancestry who were the victims of 
ovarian disease? Are there not, then, better grounds for the per- 
formance of Battey’s operation than those for which its illustri 
ous founder instituted it? This is admittedly debatable ground 
and through due deference for the opinion of those whose 
reasons for dissenting are sacred, I do not press the question. 
But let us take another illustration, for example, that of a 
uterus in which there is a cervical laceration and sub-involution, 
followed by displacement, and giving rise to the distressing train 
of symptoms familiar to every gynecologist. 13 
Is it any longer a matter of doubt that the modifications flow- 
ing from these altered functions are transmitted to offspring? 
Aside from the theoretical considerations already alluded to, and 
which, of themselves, would seem to settle the question, clinical 
observations leave no room for doubting the inheritability of 
such modifications. Tnis much, then, being taken for granted, 
who can estimate the benefits to posterity of the operations of 
Emmet and Alexander, and all other surgical procedures which 
result in the restoration of normal functions, or an approxima- 
tion thereto? An interesting and striking example of functional 
and structurral modifications that may be brought about by sur- 
gery, is afforded by some of the major operations; especially is 
this the case in amputations of the lower extremities. These 
amputations, when near the trunk, are frequently followed by 
decided improvement in the health and strength and bodily 
weight of the person operated upon. A number of cases have 
come under my personal observation, in which persons who had 
sustained amputations at or near the hip joint, during the late 
war, had become robust and plethoric, who prior to such ampu- 
tations were frail and anaemic. So many cases of this kind have 
been observed as to leave no room for doubt that the improve- 
ment may be fairly attributed to the amputations. 
In these cases the nutritive functions, prior to the amputa- 
tions, were so impaired as to be insufficient to meet the require- 
ments of the organism in its entirety, but with the lopping off of 
a large portion of the body, (about one-third of the body weight 
in amputations at the hip joint,) the area of distribution of nutri- 
ent matter would be greatly reduced. Hence, if the nutrient 
functions remained the same as before the operation, improve- 
ment in nutrition must certainly follow; but it is perfectly clear 
that with the increase ot the blood supply to the various parts, 
improvement in the functions of these parts would ensue. In- 
deed, the functional changes induced in the entire organism 
would be very great. The viscera, which before the amputation 
received a supply of blood inadequate for the proper performance 
of their functions, would now be amply supplied, and improved 14 
digestion, absorption, assimilation and dissimilation would be 
the result. It seems perfectly obvious that the physical and 
psychical modifications occurring in these cases are the outcome 
of functions which the surgical measures adopted have restored 
to the normal, or approximately normal, standard, and which 
prior to the operation were far below normal. 
I am not unmindful of the inadequacy, in the present state of 
surgical science, of the means necessary to the restoration of 
normal function in many surgical cases in which there is pervert- 
ed function. But this in no way affects the argument, which is 
that surgical skill should be applied as well to the prevention as 
to the cure of surgical diseases, and that it is the province and 
duty of the surgeon, a duty he owes to posterity, to exhaust sur- 
gical science in the endeavor to bring back to the normal per- 
formance of function any part or organ which may be function- 
ating abnormally, to the end that the terrible consequences of 
perverted functions may not be visited upon offspring. 
“Necessity is the mother of invention,” saj7s an old adage, 
and to urge the necessity of preventive surgery, a surgery that 
contemplates extending its benefits to unborn generations, is the 
main object of this paper. With this necessity felt and properly 
appreciated, the means will, to a large extent, be developed as 
surely as that water will find its level, or air a vacuum. 
Even now the means at our command, if employed with a view 
to preventing the transmission of undesirable modifications, 
would, it may be safely assumed, result in much good to coming 
generations; and while greatly enlarging the field of legitimate 
surgery, would lead to the improvement of surgical art and the 
expansion of surgical science. 
The operation for the radical cure of hernia, in respect of 
freedom from danger and perfection of results, certainly leaves 
much to be desired; but the brains and hands of men will not 
rest until this operation is shorn of danger, and its results are 
such as to stamp out this prevalent and growing scourge. 
I shall not venture an opinion as to whether it would be wise 
in the present state of surgical science to perform the operation. 15 
for the radical cure of hernia in all cases in which the application 
of a suitable truss has resulted in failure to cure; but if it is true, 
as I feel sure it is, that the tendency to hernia is accumulating 
through heredity, under the temporizing methods now practiced, 
and that this would be diminished or abolished by the 
radical operation, when successful, there would be much better 
and broader grounds for instituting radical measures than wThere 
no other incentive to such operation existed than the prospect of 
benefiting alone the patient operated upon. 
But these glimpsing details and brief comments may become 
■wearisome, and I must be content with this hasty and imperfect 
sketch. I hope it will be sufficient to indicate the grounds 
which, to my vision, appear large and inviting, a broad and 
fruitful field, as yet unexplored, for preventive surgery. I trust 
there is a good day coming, in wdiich lovely woman will be able 
to lay aside the abominable devices which inherited infirmities 
now doom her to wear, and in which man may put away forever 
the torturing truss, which is now necessary to enable him to 
live and “bring forth seed after his kind.’’ 
I trust you will agree that the reasons for the grounds taken 
in this paper, no matter how insufficient they may appear to you, 
have fairly stated, and not with immodesty. The man 
whose mind has been trained to scientific habits of thought 
needs no admonition to make him distrustful of the generaliza- 
tions of others, or to remind him of the fallibility of his own. 
The conclusions arrived at seem to my mind to be fully in accord 
with the established facts and logical inferences of natural sci- 
ence, and if I am right in this, it is not too much to say that the 
claims of preventive surgery are well worthy the attention of the 
medical profession. 
Some years ago Professor Huxley said: “On the evidence of 
paleontology, the evolution of many existing forms of animal life 
from their predecessors is no longer an hypothesis, but an histor- 
ical fact; it is only the nature of the physiological factors to 
which that evolution is due which is still open to discussion.” 
If this statement of this able, cautious and conscientious observer was justifiable when uttered, what shall we say of it to-day, 
when the accumulated revelations of have added 
their whole weight of testimony in its favor? Certainly it is not 
too much to say that the men whose special scientific training 
best fit them to form an opinion upon the subject, unanimously 
agree with Huxley. 
Assuming, from this high authority, that “the evolution of 
many existing forms of animal life from their predecessors is no 
longer an hypothesis, but an historical fact,” the question arises: 
Is the physiological factor, upon which we have laid so much 
stress, viz.: the hereditary acquirement of functionally produced 
modifications, a true cause in bringing about certain evolutional 
changes? For upon this factor hinges the argument we have at- 
tempted to make. If this be true, the conclusion would seem to 
be inevitable that changes of functions resulting from patholog- 
ical or abnormal conditions must also produce inheritable modi- 
fications; and the further conclusion would also seem to be justi- 
fiable that, where surgery can intervene and restore affected 
parts or organs to that condition in which they will physiologi- 
cally perform their functions, the transmission of pathological 
modifications must sooner or later cease. 
16