that his father is a Congregational minister and his name is Harold Nott. Dr. Mary S. Whetstone: I thought there might be some malaria in the system that might have had something to do with the high temperature. Dr. Head: In answer to that I would say that previous to his illness the boy was perfectly well; had never been out of the state, and never had any malarial infection. He gave a Widal reaction, and had rose spots and all the symptoms of typhoid. Pneumonia developed about the twentieth day of his illness. Dr. A. S. Whetstone: During what time did the temperature rise to 107° Dr. Head: During the pneumonia. Dr. S. M. White (Essayist): I have practically nothing to say in conclusion, except, possibly, this: In bringing out many of the points in the paper it was necessary to discuss the details considerably. I think recent work has shown us the value of bacteriological examination of the blood, not only of typhoidfever patients, but of patients affected with many other diseases, and further work will be of greater value still. The work done the past two years demonstrates very nicely to-day the limitations of the Widal reaction, on which we place so much reliFor instance, in some of these cases of typhoid fever in which the Widal reaction was absent throughout, or in which the Widal reacton was not present until late in the course of the disease, a bacteriological examination has enabled a diagnosis to be made in the early part of the second week-even by the middle of the first week-and we all know a knowledge of the disease in its early stages is valuable. ance. Dr. A. S. Whetstone: Would you say that if the disease is recognized in its early stages, that typhoid fever could be aborted? Dr. White: These illustrations have had nothing to do with that phase of the subject, but I believe that in the literature of to-day we have to study we have evidence sufficient to convince us that treatment directed toward the intestinal tract would be ineffective in aborting the disease on account of the early invasion of the tissues and the blood by the microorganism. Section of Surgery J. W. ANDREWS, M. D. CHAIRMAN J. W. ANDREWS, M. D. Mankato When the apostle Paul was making his noble defense before King Agrippa, Festus cried with a loud voice, and said: "Paul, thou are beside thyself; much learning doth make thee mad." So it is with the young surgeon. He yearns to do surgery, hence he goes to the centers of learning, spends a few weeks, at most, witnessing brilliant operations by expert operators, and from this lim ited experience, or rather observation, he goes at once into his field of practice. The operations which he has seen seem so easy and simple that his finger-tips burn for morbid tissue and scalpel. He is therefore bold, venturesome, full of wisdom, and non-conservative. He will recommend and urge operations in cases which the expert surgeon, mature in knowledge and experience, would pronounce inoperable. The haste and lack of conservatism in these young surgeons reminds one of the old adage: "Fools rush in where angels fear to tread." What I have said applies especially to that oft-performed and much-abused operation, appendectomy. But, gentlemen, I do not wish to be misunderstood as casting unjust reflections upon young surgeons, for it is not the tyro alone in surgery that is guilty of non-censervatism; he is not the only one that has been rash in operating on cases of appendicitis. Some of our best known and most skillful American surgeons have, in my judgment, not only been guilty of ill-timed appendectomies, but their teaching has led many surgeons less skillful than them selves to do likewise; and the fatalities in this operation can be counted by the thousands, when cool judgment and conservative surgery would have saved many lives. Two well known surgeons in this country have too often said, upon the platform and in print, when you diagnose a case of appendicitis, operate as quickly as you can get the patient on the table. Gentlemen, this advice, unqualified, is bad and dangerous in the extreme, and should be relegated to the dead past. It is all right and exceedingly wise to operate upon a case of appendicitis as soon as the diagnosis is made, provided that the patient is seen early and the diagnosis is made early. But right here I beg to differ from the views of some surgeons, namely, that there is a definite time-limit. By no means would I say as a hard and fast rule, if you get your case within thirty-six hours from the onset of the initial chill, operate; nor would I say, if you do not get your patient within forty-eight hours, do not operate. I am sure it is safer to operate upon some at the end of three days than it is upon others at the expiration of the first twenty-four hours. I think we should be governed more by the symptoms than by the time. If twenty-four hours have elapsed and the temperature is running from 102° to 103°, and the pulse 110 to 120, do not operate; let such a patient alone, so far as surgical interference is concerned. It has been said too often that in this condition an abscess will form, is forming, and will rupture into the general peritoneal cavity, and an inevitably fatal general peritonitis will follow; an operation will prevent this, the precious life be saved, and the operation will give the patient the only chance to get well. Gentlemen, the counsel should be in the above indicated case that an operation takes away the patient's only chance to get well. Conservative surgery steps in and says: Put this patient to bed, give him very light nourishment, possibly, as Dr. Ochsner, of Chicago, recommends, no nourishment at all, except rectal feeding; let the bowels rest, and permit Nature, who is always conservative, to build up a wall around the suppurative area; and that will save the patient from rupture and fatal peritonitis. Lest I should be misunderstood, I want to say, before I leave the subject of appendicitis, that I believe it highly conservative to operate early. I have known many physi cians who seeing and diagnosing appendicitis in the very early stage would counsel the patient and friends about as follows: This is a case of appendicitis, but it is in the first stage; it is just commencing; it may have to be operated upon, but as appendicitis is often cured with medicine, let us try for a day or two, and see what medicine will do. If the patient is not better, then we will operate. I wish to be emphatic in saying that no more erroneous and dangerous counsel could be given. It savors of ignorance; it savors of cowardice; it is all wrong, and there is nothing right in it. It is conservatism in an inverse ratio, and has cost many valuable lives. One thing upon which surgeons do agree is this, namely, if a patient has passed through an acute run of appendicitis and has sufficiently recovered to be around about his business again, then operate, that is, operate in the interval. In some forms of cancer there is as little regard for conservative surgery by some surgeons as in appendectomy. This is especially true of epithelial cancer of the lip. No form of malignant disease is more amenable to surgical treatment, provided that treatment is administered early; otherwise there is no form of malignant disease where surgical interference is more disastrous. Time is not an element in this disease. One many have an epithelial cancer of the lip in mild form for many months; indeed sometimes for several years, and the lymphatics remain uninfected. But if the neighboring glands are involved, then I say conservatism demands non-interference surgically. I am aware that in this position, many physicians, more able than myself, will differ with me. They will attempt to substantiate their position by saying that, if in that condition the diseased glands, as well as the cancer itself, are all removed, in that way a radical cure is effected. This is a beautiful theory and is theoretically true, but practically it is untrue. Practically true, if every particle of diseased glandular tissue could be removed; but as a matter of fact it is not, and a surgical operation is like running a rake over a smouldering straw-pile: the straw will all burn without the rake, but it will burn quicker after the rake, because new avenues are opened to which the fire will spread. In these cases where the disease has so far advanced as to produce involvement and induration of the neighboring glands, the patient and his friends are too often told that an operation, while it will probably not save, yet it will prolong, the life of the patient and will alleviate suffering. I do not believe it does, either. On the contrary, it shortens life and augments suffering. Again, I have heard physicians express themselves in pauper cases, as follows: The patient will die anyway, and he might as well contribute something to the science of surgery by submitting to an operation and allowing his physicians to watch and chronicle the results. This is exceedingly reprehensible. It is wrong in principle, and is non-conservative surgery. I have also seen some of our ablest and most conscientious surgeons remove epitheliomata of the lip in far advanced cases. I now have in mind two that were operated upon by a surgeon of eminence in the profession and skilled in his work. Both were most disastrous. Scarcely had the wound healed when the cancerous growth took on renewed and rapid action, and the only effect the operation had was to shorten life. Any surgical operation should relieve suffering and prolong life, and if it will not do one or both of these, it is not justifiable. I repeat, if epithelioma of the lip is not operated upon before the neighboring glands are involved, the surgeon had better let it alone, and turn it over to the hands of the physician to keep it clean and to relieve the suffering with opiates. What I have said of cancer of the lip is likewise true of cancer of the breast and uterus. In the whole domain of surgery there is no field where so many ill-advised and unwarrantable operations have been performed as in the female pelvis. Could we be presented with correct statistics relative to the removal of ovaries and tubes we should simply be appalled at the great number of these organs that have been needlessly and ruthlessly removed. Not only has their removal been unnecessary, but it has been positively harmful. In the Spring of 1890, when I was doing post-graduate work in New York, one eminent surgeon of that great city was facetiously called by the students "Ovaries and Tubes," because of the great number of macroscopically healthy ovaries and tubes removed by him. These rash operations have taught the profession a lesson in conservatism, but the goal is not yet reached. The late and lamented Professor Carl Schroeder, of Berlin, was the first to sound the tocsin. He was the first to resect an ovary; that is, to dissect out the diseased |