“‘The burden of the following remarks is that those only should practice surgery who by education in the laboratory, in the dissecting-room, by the bedside, and at the operating-table, are qualified, first, to make reasonably correct deductions from subjective and objective signs; secondly, to give sound advice for or against operations; thirdly, to perform operations skillfully and quickly, and, fourthly, to conduct wisely the after-treatment.
“‘The task before me is a serious criticism of what is going on in every community. I do not single out any community or any man. There is in my mind no doubt whatever that surgery is being practiced by those who are incompetent to practice it—by those whose education is imperfect, who lack natural aptitude, whose environment is such that they never can gain that personal experience which alone will really fit them for what surgery means to-day. They are unable to make correct deductions from histories; to predict probable events; to perform operations skillfully, or to manage after-treatment.
“‘All surgeons are liable to error, not only in diagnosis, but in the performance of operations based on diagnosis. Such errors must always be expected and included in the contingencies of the practice of medicine and surgery. Doubtless many of my hearers can recall cases of their own in which useless—or worse than useless—operations have been performed. If, however, serious operations are in the hands of men of large experience, such errors will be reduced to a minimum.
“‘Many physicians send patients for diagnosis and opinion as to the advisability of operation without telling the consultant that they themselves are to perform the operation. The diagnosis is made and the operation perhaps recommended, when it appears that the operation is to be in incompetent hands. His advice should be conditional that it be carried out only by the competent. Many operations, like the removal of the vermiform appendix in the period of health, the removal of fibroids which are not seriously offending, the removal of gall-stones that are not causing symptoms, are operations of choice rather than of necessity; they are operations which should never be advised unless they are to be performed by men of the greatest skill. Furthermore, many emergency operations, such as the removal of an inflamed appendix and other operations for lesions which are not necessarily fatal—should be forbidden and the patient left to the chances of spontaneous recovery, if the operation proposed is to be performed by an incompetent.
“‘And is not the surgeon, appreciating his own unfitness in spite of years of devotion, in the position to condemn those who lightly take up such burdens without preparation and too often without conscience?
“‘In view of these facts, who should perform surgery? How shall the surgeon be best fitted for these grave duties? As a matter of right and wrong, who shall, in the opinion of the medical profession, advise and perform these responsible acts and who shall not? Surgical operations should be performed only by those who are educated for that special purpose.
“‘I have no hesitation in saying that the proper fitting of a man for surgical practice requires a much longer experience as a student and assistant than the most exacting schools demand. A man should serve four, five or six years as assistant to an active surgeon. During this period of preparation, as it were, as much time as possible should be given to observing the work of the masters of surgery throughout the world.’
“While Dr. Richardson’s ideal may seem almost utopian, there being so wide a difference between the standard he would erect and the one generally established, we must all agree that however impossible of attainment under present conditions, such an ideal is none too high and its future realization not too much to hope for.
“While there is being done enough poor surgery that is honest and well intended, there is much being done that is useless, conscienceless, and done for purely commercial ends. This is truly a disagreeable and painful topic and one that I would gladly pass by, did I not feel that its importance demands some word of condemnation coming through such representative surgical organizations as this.
“The spirit of graft that has pervaded our ranks, especially here in the West, is doing much to lower the standard and undermine the morals and ethics of the profession. When fee-splitting and the paying of commissions for surgical work began to be heard of something like a decade ago, it seemed so palpably dishonest and wrong that it was believed that it would soon die out, or be at least confined to the few in whom the inherited commercial instinct was so strong that they could not get away from it. But it did not die; on the other hand, it has grown and flourished.