Surgery Outside the Hospitals.
The general tendency of operative work to drift into
the hands of hospital surgeons, which has made itself so
manifest of recent years, is a matter of considerable
interest to the medical profession. But it is really a
matter of even more importance to mankind at large,
for it would indeed be a sorry outcome of all the increase
of knowledge which has been gained by so much labour
if, instead of leading to greater perfection of surgical
work among the mass of the profession, it were merely
to lead to the concentration of surgical practice upon
that small number within the profession who are able
to obtain hospital appointments. Yet such has been the
tendency. To many an aspiring surgeon a visit to a
thoroughly up-to date operating theatre is a depressing
experience, for he feels, and sometimes he is even made
to feel, that to attempt to enter upon the higher walks
of surgery without the aid of such helps and appliances
as he finds there on every side, is almost an impertinence.
And there is something to be said for such a view. The
surgery of to day does not concern itself merely with
doing operations which are urgently necessary, and
without the doing of which the patients would quickly
die. Modern surgery is to a large extent a surgery of
election. Operations are done not merely because
they are necessary but because they are considered
safe; this safety hinges almost absolutely upon the
maintenance of asepsis; and if it is true that such
a degree of asepsis as is essential for the safe per-
formance of operative work can only be secured by the
elaborate and costly surroundings provided in modern
hospitals, then good bye to surgery for the ordinary
practitioner, and good bye to the benefits of surgery
for that large portion of mankind which dwells outside
the reach of hospital treatment. Yet the tendency to
restrict operative work to hospital surgeons is one
which is strongly supported not only by the public,
which always votes for specialism, but even among our
profession. It is only quite recently that it was urged
by a well-known American surgeon that " modern
surgery is best done in hospitals, which can afford every
facility for clinical investigation," the view taken being
that the constant bacteriological testing of surgical
technique, which is only possible where there is a per-
fectly equipped clinical laboratory, " is the first requi-
site for work of a high standard."
Although this is in a sense true, and although it is to
be admitted that operative surgery of the highest type
is most easily performed where every possible appliance
is at hand, the teaching that the practice of surgery
should be more and more confined to those who have
these advantages, and that the rest of the profession
should accept a humbler role, and should, in commercial
phraseology, become the country agents of great
operating firms, is one that we should very sorrowfully
and reluctantly accept; and all the more so since recent
surgical developments have shown that what may be
called emergency surgery demands surgical skill of the
highest type. If it were true that emergency surgery
need only be a sort of " first aid " it might be reason-
able to argue that the greatest good to the greatest
number would be attained by ordinary surgeons restrict-
ing their ambitions to simple proceedings, and sending
straight to hospital every complicated case. But this-
is no longer the position of affairs. Nothing is more
clear than that if the best is to be done in purely
emergency work the surgeon must be possessed of a high
degree of surgical skill, and must be able to carry out
his proceedings without delay and with the same degree
of asepsis as is found necessary for the highest class of
work done in hospitals. A man gored by a bull, a " run
over " case with perhaps a rupture of the liver, a woman
with a perforated ulcer of the stomach?all of them
emergencies which may occur in the remotest country
village?require for their proper treatment the highest
type of operative surgery, and men able to tackle such
emergencies properly need not stand aside from any
surgery that is likely to come in their way.
Those then who despair of surgery outside hospitals
are placed in a serious dilemma. Either emergencies
must be bungled or surgery must be rendered possible
even without the gorgeous appliances which we see in
hospitals. Under these circumstances we turn with
some relief to an address recently delivered by Mr.
Lockwood, before the Leamington Medical Society, on
the organisation of aseptic operations, in which he laid
it down that the necessary perfection of asepsis can be
attained by attention to details which can be carried
out as satisfactorily, although perhaps not with the
same ease, in a private house as in a public hospital.
Everyone knows how high is the ideal of asepticity
which Mr. Lockwood sets up, and how he has
worked for years proving each step by which he
hopes this ideal may be reached, and with this in
view it is interesting to find him speaking as follows:
" To my mind, one of the leading characteristics of
aseptic surgery is its extreme simplicity. I do not know of
any detail which cannot be carried out in a private house
as well as in the most elaborate and expensive operation
theatre." To the few the hospitals will perhaps always
offer the highest skill and the greatest facilities. But
in proportion as hospital machinery is glorified, and
the popular superstition is spread abroad that without
hospitals good surgery is impossible, the development of
surgical skill among the profession at large will be held
in check, much to the loss of mankind. Bacteriological
investigation in clinical laboratories does good and
admirable work in elevating the standard of asepsis-
within the hospitals. But for the benefit of the
ordinary workaday world it perhaps does even better
work still when it is able to evolve an organisation of
operative proceedings, a routine if one likes to call it so.
by the adoption of which a surgeon may cut himself
adrift from his base, and without the support of a
bacteriological laboratory, or the aid of an elaborately
fitted operating theatre, may go out into the world and
do good surgical work.


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