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the vagina, the endometrium, the Fallopian tubes, and, as a result, we get salpingitis, pyosalpinx and pelvic peritonitis, with adhesions of the ovary, the peritoneum, the intestines, the bladder, and in some cases all the tissues are bound down in a mass, and sometimes we cannot find the uterus at all. Now, it is not always necessary to do abdominal section; again, it is imperative that it be done. A vaginal hysterectomy will not suffice where the adhesions are too great; therefore abdominal section is called for. In such cases the woman is perfectly disabled and is not able to perform her daily work; she cannot be a housewife; she is nothing but a miserable invalid. Here surgery must be resorted to. If the ovaries are irreparably diseased, take them out entirely, and the uterus with them. What is it good for if the tubes and ovaries are removed? Again, if we find the tubes irreparably diseased, and the uterus unsound, with the ovaries healthy, then those tubes and the uterus should be removed and one or both ovaries left. The surgeon should make it his duty to save even a part of an ovary if the whole organ cannot be preserved. I repel the charge that Dr. Lee is operating on everybody. It is not true. I do nothing but surgery. My patients come from a wide section of country, and, of course, I operate often, but I do not unsex every woman who comes to me.

DR. PRATT: I believe there are more people lost who could be saved by surgery than who are operated on unnecessarily. I believe that home ties are less often broken or destroyed by a skilful operation than by the too-long deferred operation or the entire lack of it. You can't prevent the abusing of anything; that goes hand in hand with the original. When mortals were first ushered into this world, death and disease came with them. Surgery is a last resort; it is an admission that we ought to be better doctors; but so long as we are not better doctors, we must do the best we can; and good men do not carry it to extremes. There are enough cases that need operating all over the country without unsexing those who do not need surgical treatment of any kind; and if every case that is operated on was inspected publicly, they would show that they were cases that needed just such work. Because Dr. Lee has operated thirty-four times for retroversion in a year does not make his labor a fad. That is all nonsense. He is one of the most skilful surgeons in this country. Those who are not making the examinations are the fadists. The are trying to create the impression that surgery is unnecessary; they are endeavoring to push the office of medicine beyond its legitimate sphere. We would like to see rational practice. We want to know what marked deviations there are in the organism for which the knife must be the remedy. You can't prescribe for something that you don't understand; and don't talk about a thing that you don't know anything about. Evidently Dr. Wilcox was not in the surgical bureau or she would have heard of a number of operations upon the male sexual system that might be

classed with those of her own sex in degree and number of operations. Castration is a subject that is being discussed and thought about just now all over the land, not only for men with legitimate troubles but for mental conditions, and it is being discussed by lots of surgeons, especially for those who are inclined to get rabid. It is an unjust imputation on our sex to say that we surgeons think only of unsexing women; that cutting and maiming never falls to the lot of the male. I believe that the proposition is a true one, that the irritation of an organ begins at its mouth. If a woman has retroflexion and laceration, the first thing to do is to dilate and curette and repair that laceration. The great majority of the gynæcologists do not know about the removal of that cicatricial plug. It is the laceration of the internal os that causes the trouble. Dr. Pratt spoke at some length reviewing the process of disease when it begins at the mouth of the organ. He traced the capillary circulation, and connected it with the disease-bearers of the body to distant points, as in the instance of lockjaw. Then he went over the different diseases of the ovaries, the tubes and the uterus, minutely detailing the avenues through which the poison may be and is conveyed, and how to give relief to the poisoned and diseased part. He combated the idea all the way through his argument that he encouraged operations when they were not needed. He repeated that he sent as many cases home without operation as any other surgeon or gynæcologist. He was convinced that the bloodless operation for vaginal hysterectomy had many points of excellence over all the other methods of extirpating the uterus. He described the kind of cases, and again repeated the operation in detail. He did not believe that the litigation of the ovarian and uterine artery were necessary in the vaginal hysterectomy, and therefore he did not tie them, unless by some accident they were wounded. The matter of the iodoform gauze was new to him. He remarked what Dr. Boothby had said in its disparagement, but he thought the fault was more in the application than in the use of the gauze. Dr. Pratt also defended his objection to the clamps and ligatures, repeating very much his argument as stated in his paper.

WM. D. FOSTER, M.D.: In regard to the proposition whether surgeons remove the uterus too often or not often enough is a question that will commend itself to our consideration. I have done this operation frequently in the last few years, and was struck recently by a remark made to me by a trained nurse from Boston, who is a magnificent specimen of an educated lady. We happened to have about that time a good many surgical cases which she took care of in Scarritt hospital. She said: "When I first came out to Kansas City I thought the surgeons in this country were perfect butchers. We didn't see in Boston any such operations as we have in this hospital. Your operations here are more severe and diffcult than there." I asked what was her explanation of the fact? She

said in the East there are fewer poor doctors than there are out on the Western plains and in Kansas; there are large tracts of country without any physician of any kind, and other places where there are poor doctors-poor in the sense of being ill-educated-having had no advantage and lacking skill and experience. So these cases of uterine, ovarian and other abdominal disease which, in the East, in Boston, in New York and other large cities fall early into the hands of educated and experienced physicians, never or rarely get as far advanced as they do in the West before surgical interference is had. Possibly, also, the people are better acquainted with their own conditions than with us, and do not permit themselves to run along as they do sometimes here and farther West from sheer necessity. Cases come to us at a period when we cannot, dare not, operate upon them. So I undertake to say that we do not do one hysterectomy where we ought to do one hundred.

A. BOOTHBY, M.D. : In regard to the matter of drainage, I want to defer that discussion until next year, because it is of too much importance to try and answer to-day. So that I make no allusion. to the criticism in regard to my remarks as to iodoform gauze as a drainage. I have come out West and I have not found the physicians so very ignorant as some have represented them to be. I have been very much pleased. The physicians here are apparently as well educated as we are down East. I certainly do not endorse any criticism on the physicians of the West. From all I have found and seen and heard I am ready to say that they have no need to be ashamed of themselves on account of their education.

DR. LUDLAM: It seems to me that the present cry against the frequency of hysterectomy is on a parallel with the old cry which some of us remember that went up against the operations for ovarian tumors and against laparotomy. A few years ago almost all physicians were opposed to laparotomy, and ovarian tumors were allowed to go on to develop and become absolutely incurable and irremovable. So that we used to let a good many go on to destruction that might possibly have been saved through the operation. That there are many malignant diseases which require prompt ablation of the uterus is or should be evident to every conscientious physician. The only great difficulty under which we now labor is the proper indication for doing the hysterectomy. Who sees a case of vesico-vaginal fistula nowadays? Yet we all of us remember their frequency but a little while ago. How do we account for their absence now? Perhaps because the doctors are learning more about the use of the obstetric forceps than formerly. Because we have better obstetricians; because every student in our schools is drilled in the handling of the forceps and taught to use them early. Now that we have got better general practitioners we shall not have so many cases of uterine cancer brought to us in an inoperable stage.

1HE EVILS ATTENDING THE AMERICAN OPERA

TION.

BY JAMES C. WOOD, M.D., CLEVELAND, O.

THE so-called American operation, from an artistic standpoint, is an ideal operation for hæmorrhoids. The entire diseased area can be removed, healthy mucous membrane can be brought down and made to cover the newly created raw surface, whereby the hæmorrhoids are radically and effectually cured. In the hands of an experienced operator the operation can be quickly done, and, unless the patient is markedly exhausted, the immediate dangers are not, in my opinion, such as to deter the surgeon from resorting to it. After experimenting with the Whitehead, the clamp and cautery and the ligature operation, I was, therefore, more than pleased with Dr. Pratt's newer method when he first introduced it. The destruction of the entire pile-bearing inch, when the disease is at all extensive, at once appeals to the surgeon as being in harmony with broad surgical principles, and so it is. But the ultimate test of all surgical procedures must be the results obtained. The American operation should now be weighed in the balance of experience, for it is no longer an innovation; if found wanting, or if the dangers attending its execution are such as to make it wise to cast it aside for more conservative and safer procedure, I for one want to know it. Let me, therefore, at the very beginning emphasize my position.

I am deeply obliged to Dr. Pratt. I believe that he has done more than any other living man to compel the attention of the profession to the importance of pelvic reflexes, a subject which has long been of deep interest to me. The knowledge I have obtained from the teachings of Dr. Pratt has been invaluable to me. It always requires a man of strong individuality to impress great truths upon the masses. Such qualities are possessed, to a large degree, by Dr. Pratt. Yet radical teachings by radical men are never attended by unalloyed good, and this is pre-eminently so regarding pelvic lesions. This was true of Emmet's cervical operation, of oophorec

tomy and many other surgical innovations which have now found their level and should no longer be performed with unwarranted frequency. Our surgical friends have coralled the appendix vermiformis, and the first symptom of a colocynth colic is the signal for an appendicular sacrifice. The Homoeopathic profession has seemingly gone daft over the American operation. Every tyro in surgery is performing it and the land is overflowing with its victims. It is for the purpose of calling attention to the evils of the operation, as well as to court a free discussion of the subject that this short paper is written. If the sequelæ are due to faulty technique much good should come from such discussion.

I need not tell those of you who have often performed the operation, that the two complications to be contended against are incontinence and stricture. I have now performed the operation about fifty times, and have on my hands from my own list of cases two of stricture and one of incontinence. Besides these I have had many cases come to me from the hands of other surgeons with the same trouble. I know of one man, the victim of absolute incontinence, who declares he will shoot, on his first opportunity, "the author of his ruin." Some six weeks ago Professor G. J. Jones requested me to see with him a prominent judge in the city of Cleveland who was a terrible sufferer from hæmorrhoids. An examination revealed a mass of vascular tumors as large as a hen's egg which projected from the anus. It was no uncommon thing for him to saturate his clothing and his chair with blood. I, of course, urged upon him an operation, as the two surgeons who preceded me had also done. His reply was that no less than four of his intimate friends had had the American operation and all were left in wretched shape-two having stricture and two incontinence. He, therefore, most politely, but emphatically, declined to have the knife used upon him. I cite this instance to show that the complications mentioned are not ununcommon-I know that they are not from personal observation. Nor have the unfortunate cases come to me alone from the hands of novices, for some of them were operated upon by men whose surgical skill and authority are beyond dispute. I have written to many of our best men who advocate, or did advocate, the operation, and nearly all admit that the accidents enumerated are not infrequently met with.

In justice to Dr. Pratt, it is but fair that I should state that I

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