DISCUSSION.

DR. D. B. JAMES: I would like to say a few words in regard to Dr. Chase's paper. In the first place, I congratulate the doctor most heartily. His is an excellent view to take, but the trouble is, if we start in with conservatism where will conservatism end? I believe that the best policy is not to sacrifice any more than we can help, but on the other hand we must remove sufficient of the inflammatory trouble, or the seat of trouble, to insure perfect recovery. We must take into consideration the social life of the patient. In our hospital work cases must be cured in a hurry. They depend for their livelihood upon their ability to work. The consequence is they must be cured in a hurry. We operate numerous cases, I dare say, that would improve and give just as good results if we could treat them locally by placing them in a ward or in bed, had they an opportunity of being so treated. Apropros of Dr. Gramm's question awhile ago as to the way the Germans treat the bowels, why do all the German operators take out everything? They go to the extreme that we are trying to avoid. In ninety-nine cases of double high oophorectomies in the Vienna Hospital, there will be total obliteration of the organs. They go on the theory that they have infection simply by continuity of structure, if it be of gonococcic origin and there is lymphatic involvement. The consequence is, they say, the infection must be in the uterus. Remove only the endometrium and we will have it then in the metrium. The consequence is we are leaving behind what started the inflammation which in all probability has affected, on account of proximity, the myometrium and endometrium. If you remember the anatomy of the uterus, there is a very slight layer of cells, if any, separating the two. The endometrium seems to protrude into the metrium. The consequence is we are likely to have infection of the uterus. In consequence they remove everything. They claim that to leave behind the seat of origin is going to cause trouble again. If we remove only a portion of the ovary we still retain the function of the organ. That procedure I believe in most heartily. The trouble is if we remove the tube we find that the majority of infections have extended so far along the tube that if we curette at the same time to remove the seat of trouble we will awaken inside trouble that is liable to extend out into the myometrium. Operators will probably recall a number of such cases. I recall one particularly where we curetted against our best judgment less than

two weeks ago, and she was operated last Friday because we had awakened an old inflammatory condition that had been dormant for years. If we curette before operation, and then remove a portion of the tube, the chances are we are going to set up infection in the part remaining. The consequence is we have some of the remaining inflammatory condition that is going to cause almost the same trouble she had before. Conservatism is no doubt a proper thing. We must use individual judgment in all cases. Every case is a law unto itself.

DR. G. B. ROBERTS: There is so much to be said upon this paper that one would hardly have time in five minutes to really get into the discussion. I hope that anything I may say which disagrees with the previous speaker will be taken merely as an expression of opinion. I have great faith in medical treatment of these cases early in their history, but that medical treatment does not include the use of the ice bag. I believe the ice bag theory is merely a theory. We cannot cool a broad stream of tissue down where germs are actually growing. I doubt whether there would ever be shown to be an actual good result from the use of the ice bag either in appendicitis or cases of salpyngitis. The great wave of radicalism involved the removal of the ovaries, tubes and uterus in many cases in which there was no microscopic or well recognized disease, but we have now swung to the other side. Men are trying to save organs which it is doubtful if it is possible to save. I think the attitude taken by the gentleman on the left a short time ago is a very sensible one. He simply hints at the fact that we are likely to err on the other side. The doctor who read the paper speaks of several cases in which there was no death, but does not tell the later history of those cases; but I believe if he will go over his cases he will find many of the women he mentions had to be operated on again, and many who were not operated on again would be much better off if they were. It is quite impossible to bring back to a state of health by such an operation as currettage a uterus which has once become infected. The infection involves not only the endometrium but the myometrium, and it is impossible to remove it, and no doubt we have had much suffering caused by currettage. The doctor speaks of opening the tubes, so that uterine drainage is accomplished. Recall in trying to do this the uterine opening will hardly carry a bristle. Any instrument passed through it involves great danger of breaking through into some portion of the tube which is not the mucous canal,

and thereby setting up more trouble. My own personal experience has been that with this wave of conservatism I have felt it is wrong to remove these organs if we can possibly save them, but I have had some very unpleasant results from my attempts, and I believe where we find the tube infected that the safer way is to remove that tube and the upper portion of the uterus and the other tube. I know it is radical ground. I restrict this operation purely to cases of infection, but I believe ultimately this will be done in almost all cases requiring removal of the tubes. Criticism is made that heat flashes, loss of sexual desire, and so forth result, but you must recollect these are only the ordinary accompaniments of the menopause. When we remove these organs there is nothing in the history of medicine to show that we do other than bring on the menopause a certain number of years earlier. It is a disadvantage. We do not like to do it, but we are in the quandary and must get out of it the best way we can. Taking the word in general I am not in favor of conservatism as pictured by the doctor, but rather in favor of the German method as to the removal of diseased organs entirely.

DR. H. M. GAY: If I might be allowed to add a word from the standpoint of the general practitioner, and not a very old one at that, I would enter a plea for conservatism. The trend of the argument seems to be conservatism vs. radicalism, and it seems to me the argument offered for the radical removal of the organs in this case smacks rather of the hospital or dispensary. Unfortunately all of us do not have hospital and dispensary experience in our everyday practice, and do not have to watch these cases from the standpoint of the surgeon. He loses sight of the case, but the general practitioner is up against these disagreeable symptoms from the removal of the pelvic organs. It seems to me that the invariable removal of these organs, unless there be an absolute necessity, does the woman harm: I remember one case of pseudo-gestation that was operated by a very good operator and the tumor was removed. There had been many syptoms prior to that, of course, some symptoms of bleeding and some slight fever, but the tumor caused by pseudo-gestation was removed, whereupon the doctor went over to the other side of the uterus, picked up the tube, and said, "Well, I don't like the looks of this tube." I looked at the tube. I could not see anything much the matter with it. True, there was evidence of inflammation there, but there were no adhesions, no cysts, no hemorrhagic areas, but the tube upon being touched gave a kink. I said I could not deny that. The result was the woman lost her other ovary and tube, and we had a

very disagreeable time afterward controlling the symptoms. It seems to me we are not justified in taking too radical a view. Those of us who are ordinary dispensary surgeons have to cure our cases quickly, and those of us who are surgeons by profession rather than general practitioners are not up against this question, where general practitioners are.

DR. A. W. YALE: Is there not a happy medium in this matter? Cannot the diseased tube that the paper speaks of be removed and the end leading to the uterus closed, leaving the uterus or leaving one ovary, as he suggests? There is such a thing as going too far and removing too much, producing serious results. Removal of all the organs of gestation is a very serious matter to a woman, causing a great shock to her nervous system, whereas if only the diseased organs are removed, the organs which are partly diseased, such as the tubes or part of the ovaries, the shock is not so great to the nervous system. I would like to add a word to what has been said and make a plea against the large number of curettements which are being done. So many women are being curetted for slight causes, and the future results are apt to be very disastrous, unless they are done by one who is doing a large number of curettements and doing it thoroughly. Not long ago I saw a general practitioner go into the uterus and do a little scraping and a little washing. The case went by. I have no doubt it will come to a section. Whereas, if it had been done thoroughly, or probably if it had not been done at all, the woman might have been saved.

DR. N. F. LANE. I am in favor of conservatism, and very much pleased with the paper, but I am not very much in favor of conservative treatment of diseased tubes. I feel a great deal as Dr. James does about that matter. It does not matter much to the woman whether she has her tube or not unless it is very important or unless she is very anxious to bear children. On the other hand, the possession of the ovary or part of the ovary is very important, not only to the woman, but to her medical adviser. Those of us who have followed these cases of total ablation know what the result is. I think the general practitioner usually has to bear the brunt of that. So while I would be in favor of conservatism I would limit it mostly to the ovarv.

DR JULIA C. Loos. There is no reason why physicians who claim to be students of Homoeopathy, as soon as the tubes become involved, should feel that it is necessary to resort to the knife. There are remedies that go deeper than any knife, and that will do what the

knife will not do. If we remove one ovary that is diseasted and leave the other, it will not be many years before the malady goes to the other ovary. When that is taken out it goes to the nervous system. You cannot very well remove the brain and spinal cord, and you have the woman in horrible agony. Remedies will control these things, knives will not.

DR. ANNA C. CLARKE: I wish to discuss this paper because people often come to a woman doctor and say they have been to all the men, and they all advocate cutting, and they come to a woman because they think she will not do it. I do not believe in doing it unless it is necessary, but I have been called to cases where conservative operations had been performed, and where I believe it would have been well had we not been quite so conservative. I think now of a case that was operated in our hospital at home a little more than a year ago, in which the appendix was removed. At the time the appendix was removed the ovary of that side was inflamed and there was some cystic growth. It was decided to leave that ovary intact. I was there and wanted the ovary removed, but it was thought best to leave the ovary because it was more conservative. I have the patient back on my hands with a growing ovarian tumor, and another operation in view. If it had been removed at the time of the first operation I do not believe the shock from the anesthetic and from going into the abdomen would have been greater, and I think it would have paid us to do so. I have another case on hand in which an ovary was removed several years ago. At that time they said the tube was enlarged on the other side, and for a number of reasons the other ovary was left. That patient is under my care now with reflex trouble from a diseased ovary, and she should have it removed. She says she will die before she will have it out, because she nearly died under the other operation, and if they could not take out all the diseased parts at that time she has no assurance they will do it if she is operated again. I can think of a number of cases of that nature where if the work had been done thoroughly at the time we would have had better results. If an organ is diseased, and if we have tried our remedies before we risk an operation, we have no right in my estimation to open the abdomen and leave diseased tissue in there which we think will give trouble.

DR. J. E. JAMES: Most of these cases come to a surgeon or a gynæcologist after the remedies have been tried, after the physician has tried for weeks, months and years all the remedies of the school