stantly changed, for thereby-as by frequent vaginal douches-the successive generations of germ cultures that are attempted are prevented and the ptomaïns are carried away.

DR. ILL (closing the discussion).-The method I have described is not that of permanent irrigation. The introduction of six centigrams of an alcoholic solution does not make permanent irrigation. The point that is made by the introduction of this solution is that it will disseminate amongst the gauze and touch every portion of the uterine cavity. Permanent irrigation has been found to be faulty, in that the solution flows out alongside the tube, and remote portions of the uterine cavity are not touched by it.

POST-OPERATIVE LESIONS AND SEQUELA.

THEIR EXTENT, CHARACTER, AND HOW TO DEAL WITH THEM.

BY JOSEPH PRICE, M.D.,

PHILADELPHIA.

IT must have come to the notice of many of you that there are numbers of useless, often harmful operations. It seems a common affair for surgeons, or those passing as such, to work some little end at the expense of all the risk of a regular operation. They have only in view some temporary or peculiar benefit, without sufficient consideration of the subsequent work necessary to complete cure. Our great aid lies in the recuperative abilities of the patient; and what can one expect when her vital powers are taxed for recovery from numerous ill-judged operations? It is surely a matter for considerable caution. The excuses are few for repeated operations. We will view repeated operations from two standpoints one is where pathological conditions and the broken-down condition of the patient are such as to render a complete operation of extreme peril to the patient. To determine this question, the extent to which procedure is safe, is one of the most serious that appeals to surgical judgment. It is only such conditions that justify leaving anything for a second operation. The other and more frequent reason for re-operation, the one least to be justified, the one a reproach upon our surgery, is the attempted work of ignorance or that which cowardice leaves uncompleted. There is an explanation of the necessity for many repeated operations, which we give with a sense of regret. The commercial element repeatedly enters in with a resistless influence; there is a money motive -this where the life of a human being is involved! The reasoning is from any other than a high professional standpoint. "This is a paying case; I will go as far in this case as is absolutely safe.

I will give temporary relief, secure the patient a brief period of comparative comfort, and when the trouble returns in aggravated form the patient will go into other hands for complete removal of the trouble, with probable if not very certain increase of some one's statistics of mortality." This is the conduct and reasoning of too many. Statistics have become too much a matter of mere advertising concern, and are therefore of little value. All of us are concerned in our mortality, all want our patients to recover; but mere recovery from an operation does not in very many instances mean a cure; the terms are not synonymous. Indeed, the condition of the patient, after so-called recovery from certain operations is worse, the suffering greater, the life in greater peril than before. Mere experiment is responsible for very many repeated operations. This experimenting is not limited to the youngthose fresh from our college benches. Experience convinces me that many of our young men are more conscientious than some of their seniors. They push their special work until they have a fitness for it. This they can afford to do, for when they begin they will know how, and therein lies the secret we are all seeking.

Leaving this side-play, let us talk surgery; and permit me to say it is difficult to talk it wisely, more difficult to practise it wisely. In every case there should be a very reasonable certainty as to existing trouble, otherwise it is impossible to determine upon the method of treatment. But the error is not always of diagnosis the operator may be moved by the craze to operate. The subjects of these unjustifiable operations-operations for slight or undefined troubles-receiving no relief, will permit a real trouble to grow until conditions become such that relief by the most skilful surgery is difficult and of uncertain result. In many of the cases of repeated operations the primary operation was unjustifiable; there was error of diagnosis; doubt and speculation in the mind of the operator as to existing trouble. The primary operation may create conditions, set up adhesions, which make the second operation difficult and dangerous. All forms of exploratory operations imply ignorance and doubt, and are responsible for much of the work which has to be repeated. It is true that there are cases where an exploratory procedure serves a good purpose, and, when done under proper surgical method and with absolute cleanliness, involves no great risk to the patient. It should be kept in mind

that all surgical procedures involve more or less risk. The tolerance of the peritoneum has tempted to a great deal of surgical nonsense, often to a carelessness or rashness which sets up pathological conditions requiring radical surgery for their correction. We will name a few of the procedures which give us a large percentage of second operations: 1. Dilatation and curettement. puncture. 3. Vaginal hysterectomy.

2. Vaginal

Then comes the operation that cures-abdominal section, the freeing of omentum and bowel, both large and small, the removal of pathological conditions, irrigation and drainage. The class of patients upon whom repeated operations are most frequently required are the well-to-do, those who can afford to go to Florida, to Paris, to travel about the world consulting specialists and all kinds of men-men with fads, some very much like those species of fish with both eyes on one side of the head, unable to see but one side of an object, that side only too frequently the financial side. The patient is advised to numerous forms of treatment, very frequently treatment which only aggravates the condition. Along with the treatment I have named, the rest cure comes in. The rest cure has its field; but when we have to deal with certain pathological conditions we must recognize that there is something more than rest needed. Rest cannot correct diseases of the pelvic vis

cera.

In appendicitis a second operation occurs to relieve obstruction or break up adhesions which were the result of the incomplete primary operation. In many of these cases, as in others, the complications are so great and extensive that the operator, not having the knowledge and skill, or lacking courage, abandons the procedure with the entirely too common apology, "inoperative,'

hopeless." The freeing of visceral adhesions in primary operations is rare, and for this reason very much work has to be gone over again with all the difficulties aggravated tenfold. Too many operators are content with the simple removal of a growth, with correcting the fixation or pathological conditions about it. A partially adherent bladder, if not freed, will remain a perpetual source of annoyance. Bands of adhesion about the ileum, if not freed, form the post-operative obstruction we see so commonly reported. The removal of remaining and irritating material, careful trimming of all ragged, fringy adhesions, clearing away of all débris and clot, and well-placed drainage at the seat of oozing, will favor a perfect

cure. It is sometimes necessary to retie old pedicles when portions of an original cyst or tumor remain in the pedicle, and cut or scrape with a short knife the dirty seat of dead ligatures and stitch healthy peritoneum over those parts. The surgery of the rectum and sigmoid from the intrapelvic side has not been written. In most repeated operations the cicatrix and ventral hernia require detail and painstaking surgery. The repair of the omentum, commonly adherent to cicatrix in pelvic viscera, is important.

Unfortunately, too many poor women continue to suffer from post-operative lesions; they are told to have patience, that the symptoms will vanish. Very frequently there is opposition on the part of the physician to reopening and correcting the mischief ; some look upon visceral adhesions as necessarily fatal. A few do not consider an operation complete until all visceral adhesions have been carefully freed and repaired and left in as normal condition as possible; after the repair of viscera for the removal of growths, placing all viscera in pathological relation. A number of operators remove tumors without examining surrounding parts. When we hear of a case operated upon two or three times by the same operator we have no difficulty in forming an estimate of his surgical ability. We know that in his primary operation, in his second and probably third venture, he left something behind he should have removed; all through he was doing incomplete work. We fully recognize that too much surgery in extremely debilitated patients will kill just as surely as none at all. Methods of procedure have much to do with the necessity for repeating operation. As an illustration of this fact, I will refer to a very recent case of my brother, Dr. M. Price. There will be no difficulty in drawing conclusions from the report. The patient was referred to him for operation. It was found the woman was suffering with an abscess on the left side extending above the umbilicus; pulse 120, temperature 102°; leaking badly; septic in the extreme; uterus fixed; fluctuations in the pelvis easily determined. A diagnosis of pelvic abscess was made without hesitation. The abdomen was opened from above. The bowel, omentum, and mesentery were all firmly attached to the walls of the abscess, which extended above the umbilicus, and as adhesions were broken by the hands pus began to well up from under the sac as it was detached. The enucleation continued down to the depths of Douglas's pouch, over