Who and what is a surgeon?

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of THEAMERICAN ASSOCIATION FOR THE

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OF SURGERY,

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ACADEMY

THURSTON

SCOTT

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EDITORIAL WM. S.BAER,Bnlt.: ALEXIS CARREL, W. B. COLBY, N. Y.;

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JAMES T. CASE,

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UROLOGICAL

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11

‘EDITORIALS’ WHO AND WHAT

T

Chicago;

temple,

HE February, 1928 number of The American JournaI of Surgery carried an editoria1 entitIed “Surgeons, ReaI and Psuedo.” We drew attention to the obvious fact that any graduate of medicine with a Iicense to practice was permitted by Iaw to undertake any minor or major surgica1 operation. The physician’s conscience, aIone, was the guide in estabIishing the fact as to whether or not he was capabIe of assuming such surgica1 responsibiIity. Inasmuch as not “every physician” shouId be permitted to do surgery, but onIy those speciaIIy trained in this branch of medicine, we asked for a soIution of the probIem, acknowIedging that such a soIution was beyond our abiIities. This editoria1 drew a Iarge number of Ietters addressed to the editor. Many were the soIutions offered. One distinguished surgeon from Ohio said the answer Iay in State medicine. Another equaIIy we11 known surgeon said the matter shouId be

IS A SURGEON? put up to the American CoIIege of Surgeons for a soIution. A gentIeman from the southern part of Texas wrote us a peppery Ietter, asking if the “surgica1-trust” wasn’t satisfied with things as they now stand, and how was a common or garden variety of genera1 practitioner going to finaIIy make a Iiving out of the profession, anyway. A surgeon from the Northwest said it was a matter for each state to decide, but that there shouId be specia1 quaIifications and specia1 Iicenses for those cIaiming to be surgeons. AI1 in aII, we enjoyed it very much indeed and were surprised that our innocent bit of writing was so widely read and contained sufficient kick in its Iines to prompt readers to take their quiIIs in hand and address communications to us. In the end, however, the probIem was far from settIed. There is a difference of opinion about this question. Many wouId Ieave things in the present state, others wouId work for

NEW

SERIES VOL. V, No. s

EditoriaIs

radicaI changes. These changes range from State Medicine to a four years post-graduate course with coIIege examinations to earn a specia1 surgica1 degree, also, specia1 examinations, etc., in order to be Iicensed by the state. In the press of other matters we had put aside this probIem, assuring our inner self that one day we wouId revert to it. That this matter has occupied many other minds is proved by the report of a subcommittee on medica education of the New York Academy of Medicine in May, 1928, and an abstract was printed in the August BuIIetin of the New York Academy of Medicine. This abstract was entitIed; “ Suggestions for Improving Post-Graduate Teaching in the Operative SpeciaIities.” We here reproduce it: A review of the post graduate courses offered in the surgica1 speciahies in New York City gives the distinct impression that they are inadequate and that there is need for improvement. New York City with its enormous cIinica1 faciIities shouId bk the teaching center of the western hemisphere. It shouId be a pIace where speciahsts are trained and where doctors may come to improve themseIves in their respective speciaIties. There is at the present time no adequate contro1 over physicians who propose to practice a surgica1 speciaIty or who are doing surgery, nor is there any prescribed method of procedure by which one may quaIify as a surgeon. It is true the American CoIIege of Surgeons requires the submission of a certain number of case-records before a candidate is admitted to membership in that body, but there is no supervision or requirement regarding the obtaining of these records. It seems that the entire system of deveIoping speciaIists may we11 be changed. Graduation from a recognized medica schoo1 or even graduation from a genera1 hospita1 is hardIy sufficient to quaIify the average doctor as a speciaIist in any of the surgica1 branches. It wouId seem wiser to require a specia1 period of training for every physician who intends to become a speciaIist in one of the operating speciaIties. Of the many house surgeons who are being graduated from genera1 hospitaIs onIy a smaI1 percentage can ever hope to become members of the attending staff. The majority enter

American

Journal

of’ Surgery

321

genera1 practice after a hospita1 course which has been IargeIy speciaIistic, and much of the training has been wasted on them. We wouId therefore suggest that an attempt be made here in New York City to get the various hospitaIs to agree upon some definite pIan for improvement. New York University and BeIIevue MedicaI SchooI has taken the initial step in this regard by estabIishing a course of post graduate instruction Iasting 2>$ years It is composed of Iaboratory work, demonstrations, Iectures and practical hospita1 work. During the Iatter period the student assumes the position of an adjunct surgeon and actuaIIy performs operations. Such a course may we11 serve as a guide; on the other hand the foIIowing pIan may be more satisfactory for a Iarger group. The majority of the New York hospitaIs offer a genera1 course of interneship of about z years, emphasizing either medicine or surgery, as the case may be. We wouId suggest that an attempt be made to get al1 hospitaIs to agree to offer a genera1 course of one to two years to incIude medicine, surgery, obstetrics, gynecoIogy and a11 the speciaIties as far as they are abIe to, in order to fit a candidate for genera1 practice. None of these graduates however shouId be permitted to pose as speciaIists or to perform major operations. Those men who during their interneship show specia1 desire or incIination to perfect themselves in a given speciaIty shouId at the end of their period be eIigibIe for appointment as feIIow or resident to serve a given period of one to two years, during which time they shouId be given opportunity to perform major operations and to study every phase of their speciaIty in the wards, the Iaboratory, the cIinic and the x-ray department. We fee1 that there is a trend aIong this Iine at the present time, and that we in New York City shouId anticipate it and take steps in this direction. Those men who desire to take up the various speciaIties such as ophthaImoIogy, otoIogy, IaryngoIogy, uroIogy or any other subdivision shouId try to get appointments in specia1 hospitaIs devoted to those subjects or in the speciaIistic departments of the Iarger genera1 hospitaIs. The Committee recommends the estabIishment of some organization which wiI1 work out a detaiIed pIan aIong the Iines indicated. The Academy of Medicine wouId be the Iogical

American Journd of Surgery

522

EditoriaIs

institution to do so, perhaps in coIIaboration with the well-endowed medica schooIs and a11 the Iarger hospitaIs of our city that are wiIIing to co-operate. The entire pIan wouId be voIuntary on the part of the interested institutions. The Committee in charge might be authorized to confer a specia1 surgica1 degree or dipIoma on the candidates taking the course. In case the pIan proves successful an attempt might be made to make it nationa in scope. It wouId seem that the American CoIIege of Surgeons shouId have a sub-department to study the entire probIem of post graduate teaching of surgery in America. This reform

is a good start. NaturaIIy, the (how we disIike that word) wiI1 not

come overnight, or in two years, for that matter. That it is a pertinent probIem with our advancing, and day by day more compIex, times, there is no doubt. We weIcome further Ietters from our subscribers giving their soIutions to this probIem. T. S. W.

BRITISH LETTER INTRAVENOUS

INJECTION, VARICOSE

G

TREATMENT

FOR

VEINS

H. CoIt, F.R.c.s., said recentIy in a post-graduate Iecture on the modern treatment of varicose passing of the operative veins : “The treatment of varicose veins may be regarded as a mercifu1 reIease for the surgeon . . . ” It does not appear so Iong ago that we were stiI1 IaboriousIy dissecting out Iong segments of the interna saphenous and its branches. After a comparativeIy short tria1 of the injection method we are practicaIIy informed that operation seems to be no Ionger justifiabIe except in certain very isoIated cases. Most surgeons wiI1 agree that they have been soreIy disappointed at times with the operative treatment of varicose veins and uIcers and any substitute treatment, that on sound anatomicophysioIogica1 grounds wiI1 ensure better resuIts, wiI1 command genera1 acceptance. l

NOVEMBER,,925

CoIt’s paper gives a brief historica resumi: of the deveIopment of the operative methods and quotes a paragraph from Sir Benjamin Brodie’s “Lectures on PathoIogy and Surgery,” 1846, giving a very cIear account of the so-caIIed TrendeIenburg’s sign : If the veins are but IittIe diIated, or diIated onIy in particuIar pIaces, the vaIves wiI1 stiI1 continue to answer the purpose for which they were designed. If the vena saphena be not at a11 diIated, whiIe the smaIIer veins of the Ieg are diIated, the vaIves of the vena saphena act perfectIy, and take off the weight of the coIumn of bIood pressing on the veins beIow; but if the vena saphena be itseIf considerably diIated, its vaIves, of course, are rendered ineffrcient. Now observe the resuIt of this. I had a patient in whom there was an unusuaIIy Iarge cIuster of varicose veins on the inside of the leg, whiIe the vena saphena major was of enormous diameter, so that the vaIves were evidentIy good for nothing. If I put on a bandage and squeezed the bIood out of the veins beIow and then put my thumb on the vena saphena above, so as to stop the circuIation through it, I found, on taking off the bandage, the patient being in the erect posture, that the cIuster of veins beIow fiIIed very sIowIy and onIy from the capiIIary vesseIs. But if, the patient being in the erect posture, I removed the pressure from the vein, the vaIves being of no use, the bIood rushed downwards by its own weight, contrary to the course of the circuIation, and fiIIed the varicose cIuster beIow aImost instantaneously.

It must be recaIIed that before treatment by intravenous injection was tried there was an era, the Iast quarter of the 19th century, of extra or perivenous injection methods, amongst the various substances tried being soIutions of ergot, perchIoride of mercury, carboIic acid and aIcoho1. But these caused serious sIoughing and .were soon discarded. In the fn-st decade of the 20th century numerous investigators were attempting intravenous injections using soIutions of potassium iodide, and mercuria1 and arsenica preparations, notabIy saIvarsan, with definite successes. HanscheII in 1913 was successfu1 with a soIution of gummi. However it is