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diagnosis than ever; and yet the very opposite is true. The young man just out of college thinks we should be able to say exactly whether the tumor which is killing the patient is a cystic fibroid of the uterus or a fibrous cyst of the ovary. Indeed, one esteemed friend actually told me that he had delayed operation for a year because he was not sure whether the tumor was a fibroid or not, and he had been taught that fibroids should be left alone, as they often get well themselves after the menopause. That teaching nearly cost that patient her life, for as I will show later, a fibroid is a source of suffering and danger from the moment it is discovered.

While the inexperienced doctor thinks that an exact diagnosis is easy, and delays the life-saving operation until he knows exactly the nature of the trouble, we find men with an enormous experience, the Mayos for instance, saying that it is impossible to say before the abdomen is opened just exactly what will be found, and that we are making no mistake when we operate for a pus tube and find instead a tubal pregnancy before rupture. What would be a mistake, and an awful one at that, would be a conservative curetting with the patient dying on the table from internal hemorrhage, when a prompt and radical operation would have conserved the patient's life.

How many thousands of lives have been lost through the conservative treatment of cancer? The woman with irregular hemorrhages at or after the menopause has been treated for months when days were precious, with ergot or adrenalin, without an examination; and when the examination has been made more months are lost with local applications when even hours have become a question of life and death. And when we upbraid the family physician gently, and too often, alas, tell him that the time has passed for saving his patient, he puts in the plea that he thought it was cancer, but was not sure, as there was no foul-smelling discharge, and he did not like to advise anything rash. Everyone should know that a foul-smelling discharge in cancer means an order for a coffin. He is conservative in his treatment, but he is not conservative of the patient's life. Or a woman comes to him with a small, hard lump in the breast. He finds no lumps in the axilla, and, being conservative, he tells her to leave it alone and to come back in six months. She goes away delighted, not knowing that in those few conserva. tive words he has pronounced her sentence of death. When she comes back six months later with the nipple retracted and enlarged glands in the axilla he takes her to the gynecologist, who has had a large experience of such cases; but he sees by the latter's tone that it is too late to save her life, which but for his mistaken conservatism he might have saved. More than one good medical friend has told me, after the patient had left my consulting room, that that was the most unhappy moment of his life. In both of these cases, and they are happening every day, there was a time when the cancer was no larger than a pea and when operative treatment would have given no deaths and a hundred per cent. of cures; while waiting for a sure diagnosis will give an operation mortality of four or five per cent. and a mortality of 80 per cent. before three years; with only four alive after six years.

But to confine myself more exactly to the abdominal work of the gynecologist; there is here more than enough of disappointment and regret, due to mistaken conservatism, to more than fill this paper. I have forgotten all about the several hundred women who came to me with pus tubes, and who, after several years of invalidism due to peritonitis, had them completely removed, and thereby gained robust health and the restoration of marital relations. But time has not effaced the mortification of having exposed some twenty women to the suffering and danger of a laparotomy without having relieved them of their pain. Twenty years ago I only conserved one of two diseased ovaries under compulsion, after giving the woman distinctly to understand that if the operation proved a failure it was her fault and not mine. Notwithstanding this understanding, I have received insulting letters from several of them, saying, among other things, that “if I did not know how to cure them I should have sent them to someone who did.” A few even went so far as to say that I should have used my own judgment and done what was necessary in spite of their injunction to the contrary. During the last five years I must say, in justice to the patients, it has not been their fault if I have adopted this foolish conservatism. One is more or less the result of his surroundings, and it is almost impossible not to be influenced by public opinion, no matter how well we know and how anxious we are to do what is best. Consequently during the last five years I have had to do a second and much more difficult operation on at least ten women who might have easily been cured by the first one done by me; while more than ten times the second operation was done on the victims of conservative, or rather incomplete, work by other, and some of them more able, operators. Half a dozen times I have had my hand on the telephone to ring them up and tell them that Mrs. X., from whom they had removed one ovary and tube a year or two ago was in my office, suffering worse than ever, demanding a second laparotomy, but refusing to go back to the first operator. But I knew how unhappy such a message would make me, and I spared them. Some of these cases I tried to pacify by telling them that they had had a child since, which they would not have had if their first operation had been complete; but they indignantly replied that they had suffered all the time they were carrying it and ever since its birth. The most unhappy part of it is that while I am an unwilling listener to their complaints, the same number of my conservative failures are complaining to other operators of my incapacity. Then back of these women again are all the hundreds of women in their little towns who are dragging out a wretched existence, and who could be absolutely cured by a thorough operation, but are deterred from undergoing it by the bitter experience of their unfortunate sister, who because she has had another child is reported at the society as a brilliant success. I have been taken to task at a great society meeting for putting in a feeble plea for these unoperated ones. The speaker said, “I hope that it will not go forth as the opinion of this society that our treatment of any given case should be influenced in the slightest degree by the effect such treatment might have upon similar cases not under our treatment, no matter how numerous they might be.” I said nothing, but I thought his remark very heartless. But in this case it does not even apply. Women come to us for relief. They care nothing whether it is a teratoma or a gyroma that is killing them. What they want is health. They are not clamoring for more children, but for strength to take care of those they have. To them a successful operation does not mean getting off the operating table alive, but it means freedom from pain, in the abdomen at least, for the rest of their life. And if in a few months or a year after their operation they are suffering worse than ever and have to have another and more serious operation (all second operations are more serious than the first one, owing to adhesions) the idea will soon spread that once a woman has an operation she will keep on having them. This is one of the most difficult objections we have to meet when we propose an operation which is really necessary. The objection is all the more difficult to meet because it is valid. I have had more than one woman under my care who has had the following discouraging experience: First a pain in the left side, which is worse at the periods, and which has grown steadily worse in spite of medical treatment and a curetting by her own doctor. Then a visit to the gynecologist for removal of the left ovary only. At the operation the other ovary was found to be cystic and sclerosed, but was only cauterized or the cyst incised. She was just getting

. into fairly good condition when the same kind of pain began in the right side; a third operation for removal of the right ovary. Much better health for several years, and then another kind of pain with digestive disturbances, attributed to adhesions, for which nothing could be done, until one night she was taken with severe pain and vomiting came on, looking very like obstruction. Another doctor is called in consultation, and he, being unbiased by her former experience, at once pronounces it appendicitis, for which a fourth operation is performed. Then at last she gets into better health than she has had for years, and, barring the ventral hernia, she is perfectly happy. When this has been repaired by her fifth operation, which is very difficult but entirely successful, she enjoys robust health. Unfortunately while all this is going on there are several women in her town who form a sort of unsuccessful operation club, opposed to all operations, which does not help the cause of good surgery.

Now, what is the remedy for these unfortunate experiences ? First, let the family doctor do all he can to help that sclerosing left ovary and that weak appendix along. The left ovary was born with trouble, one might say, for the left ovarian vein enters the left renal vein at right angles to the current of blood, while the right one enters the inferior vena cava at an acute angle, which is much more favorable, so that it takes a year more of disease to make the right ovary as painful as the left. But as if that were not enough of a handicap, there is the loaded rectum, with a pound

a or two of hard fæces nipping that delicate left ovarian vein at the brim of the pelvis. Then there is the handicap of fashion, which applies to both ovaries alike in obstructing the venous circulation. Then there is the handicap of old maidhood, which never gives the ovaries the physiological rest to which they are entitled by pregnancy and lactation. And still another handicap of a long engagement, which keeps them choked with blood. These and many other handicaps the family doctor must remove if he can, and he can most of them if he has the patience and courage. Also let him do his best with local application for a year; in nine cases out of ten he will succeed. But if, on the contrary, in the tenth case the suffering is becoming so great as to be unendurable and the patient has to spend most of her time in bed, he has done his best and the time has come to bring her to a gynecologist who does thorough work. Don't tie his hands; on the contrary, put the responsibility on him to effect a cure, but leave him free to do all that should be done at the one sitting Let him remove both ovaries and tubes and the appendix and do a ventrofixation; and if she is an overfed woman even suggest that while he has his hand in the abdomen that he should explore the gall bladder and the common duct. Then, if he sews up the abdomen with three layers, this will be her first, last and only operation, and the chances are that she will be well. During a recent visit to the Mayo brothers at Rochester, Dr. Willie Mayo told me of a case where even he had nearly lost a patient by committing the following blunder: He had removed a pair of pus tubes in a satisfactory manner, and all went well for nearly a week, when the case went wrong, pain, temperature and vomiting. He thought there must be adhesions and obstruction of the bowel, so he reopened, but could find nothing of the kind. He was about to close in a hurry, when it suddenly occurred to him to look at the appendix. On doing so he found it hanging down in the pelvis, gangrenous and almost perforated, with a stone in the end of it and bathed in pus. He removed the offending organ and the patient promptly recovered. In spite of that lesson he had another and a final one a year later, when, after removing a large and difficult tumor, he was about to close when Ochsner, of Chicago, who was standing beside him, asked if he had not better look to the appendix. He replied: "That is not necessary; she has never complained of it." However, to please his guest, he dragged it up out of a bed of adhesions, and found to his mortification a large stone in the end of it. The woman afterwards remembered that she had had a severe attack of pain in that side when a child. Ever since that second lesson he has never failed to look at the appendix, and in most cases to remove it.

Another day, when I asked him if he ever did conservative work on the ovaries, he said most emphatically, "No. I only do two things to the ovaries—either take them out or leave them severely alone." I actually saw him put back two large cystic ovaries after a myomectomy without even emptying the cysts. IIe said that some of his most difficult laparotomies had been for the removal of ovaries which had been tinkered with at a previous operation.

About fifteen years ago I had the good fortune to hear a paper at the American Gynecological Society by Edebohls, of New York, advocating more thorough work, after which I began to do six oi seven operations at one sitting of sixty or seventy minutes, and the results have been most satisfactory. At that time we did not know much about the appendix, so it was not included in the list of combined operations. But a few years ago I read a paper entitled “Should the Appendix be removed in every case in which the abdomen is opened for other reasons ?”' before the American Gynecological Society, Niagara Falls meeting, and the discussion which ensued so thoroughly endorsed the affirmative view which I took that I have ever since carried out this plan, except in a few cases

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