CONSERVATISM IN OVARIOTOMY. HOWARD A. KELLY, M.D. PROFESSOR OF GYNECOLOGY IN THE JOHNS HOPKINS UNIVERSITY. BALTIMORE, MD. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIA TION FEBRUARY 8, 1896. American Medical Association Press, CHICAGO: 1890. CONSERVATISM IN OVARIOTOMY. HOWARD A. KELLY, M.D, PROFESSOR OF GYNECOLOGY IN THE JOHNS HOPKINS UNIVERSITY. BALTIMORE, MD. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION FEBRUARY S, 1896. CHICAGO: American Medical Association Press, 1896. CONSERVATISM IN OVARIOTOMY. I have recently received two vigorous letters, which I enclose, from friends who are doctors, upon the ethical status of the operation for the removal of the ovaries. These letters have brought vividly to mind a note which I published in the American Journal of Obstetrics, for February 1893, entitled “ The Ethical Side of the Operation of Oophorectomyl have gone over the ground once more from the standpoint of almost three years’ growth in gynecology, to see what positive advances have been made in answer to this burning question. Both of the letters are from highly valued friends, for whose opinions I have a profound respect, and in whose judgment I place full confidence; I feel under obligation to reply to them in such a way as shall effectually promote the end in view. One of the letters, the second one, is from a distinguished physician, the leading practitioner in one of our large cities, and a man of national reputa- tion. I publish both just as I have received them, believing them to be more valuable in this form, than if I had asked the writers to make alterations in accordance with any minor criticisms I might have to offer. Conservatism, the appeal of my correspondents to conscientious gynecologists, is undoubtedly the pro- gressive spirit in gynecology ; exsective and amputa- tive gynecology has gone to its extreme limits, and the more thoughtful surgeons looking at all the ques- tions involved, in their broader aspects, have already sounded the keynote of the new advance. To put the matter clearly before the minds of practitioners in general, I would cite categorically the following con- servative procedures, which replace radical measures : 4 1. —Resection of diseased ovaries and opening and draining tubes, as urged by Dr. ffm, M. Polk, of New York, in the American Journal of Obstetrics, July, 1894, Yol. xxx, pp. 1-15, and in the Transactions of the American Gynecological Society, 1893, Yol. xvm, p. 175. 2. —Myomectomy as a substitute for hystero- myomectomy, by Dr. E. C. Dudley, of Chicago, in the Transactions of the American Gynecological Society, 1894, Yol. xix, p. 126. 3. —Opening and draining pelvic abscesses poste- rior to the uterus. See “ Conservative Treatment of Pyosalpinx,” by Cornelius Kollock, in Transactions of the Southern Surgical and Gynecological Association Yol. vi, p. 43. Also “Conservative Surgical Treat? ment of Para- and Peri-uterine Septic Disease” by Fernand Henrotin in the Transactions of the American Gynecological Society, Yol. xx, p. 223; reviewed edi- torially in the Journal of the American Medical Association, June 22, 1895, p. 983. 4. —Vaginal drainage in some cases of extra-uterine pregnancy. See my article in An American Text-book of Obstetrics, Philadelphia, 1895, 5. —Excision of both large and small parovarian cysts, without sacrificing ovary and tube, in my own practice not yet reported. I do not wish to dwell on these operations now, for it is rather my object to try to arouse a more general feeling of interest in the broad moral bearings of the entire question. In doing this, I dare not omit the most fruitful of all causes of the unnecessary mutila- tion of women, and that is, the large numbers of men all over the country who are entering upon this spe- cialty without any adequate preparation, and are yet anxious at as early a date as possible to “make a record.” I have seen repeated examples of this reck- less exsective surgery, and it is my privilege every week to save women who have in some instances traveled long distances to get further advice. Only yesterday I saw a hysterical girl about 18 years old, drugged with morphin, and without any pelvic dis- 5 ease whatever, whose physician thought that ovariot- omy was clearly indicated. A patient, now under treatment for a mild trigonitis (inflammation of the vesical trigonum), came to me because her previous attendant, after some treatments applied to her ova- ries through the vault of the vagina, declared that her ovaries and tubes were diseased and must come out, or he could not cure her. And yet she has not a trace of pelvic disease outside the little trouble in the bladder. And so on, I might add case after case usque ad infinitum. I shall not, in this brief appeal to higher morals, analyze causes minutely, but I can not help adding that apart from the question of integrity involved, these men have never thoroughly learned, at the hands of a skilled clinician, the technique of the bimanual examination ; they make their diagnoses symptoma- tically, and hence the frightful errors. Nor would I lay all the blame on the untrained men ; even the best men have erred, but they have had the saving grace to report their errors for the benefit of others. As evidence of this, I pick up with little effort, the following cases of pregnancy occurring in women, the first six of whom had been advised to have their ovaries and tubes removed, but had refused, and twenty-four of whom under the ordinary procedure of the day would inevitably have been made sterile: Women refusing operation who afterward became pregnant and bore children : Dr. Wm. Goodell, two cases (Clinical Gynecology. Keating and Coe. Intro- duction, p. 10). Dr. Archibald MacLaren, one case. (Trans. Amer. Gyn. Soc., 1893, vol. xvm, p. 334). Dr. Charlotte B. Brown, one case (“Rest, a Thera- peutic Means in Gynecology.” Read before the Med- ical Society of California, April, 1895). Dr. H. A, Kelly, two cases (unreported). Cases of abdominal operations on ovaries treated conservatively, followed by pregnancy: Dr. Wm. M. Polk, nine cases (Amer. Jour. Obst., July, 1894, vol. xxx, p.l). Dr. Robert A. Murray, six cases (See Dr. Polk’s paper, just cited). Dr. B. McMonagle, one case (See Dr. Polk’s paper). Dr. B. F. Baer, one case (See Dr. Polk’s paper). Dr. Frank Talley, one case (Amer. Gyn. Ohst. Jour., March, 1895). Dr. H. A. Kelly, three cases (unreported). Dr. Matthaei, six cases, five children (Zeitschr. /. Geh. u. Gyn., vol. 1, part 2). Dr. Polk had six cases of inflammatory disease in which he conserved the appendages, with the result of nine pregnancies. Dr. McMonagle’s case was alto- gether remarkable and ought to be carefully studied by every gynecologist. In one of my own cases I opened and drained a large right ovarian abscess, and pregnancy occurred within two years. We have here then, as a result of this conservatism, either by the insistence of the patient, or the election of the sur- geon, in twenty-nine women thirty-two childbirths. (One of Dr. Polk’s patient’s, “wearying of maternity,” secured a criminal abortion to rid herself of her sec- ond conception after the operation.) These facts need no comment, and speak volumes for the recup- erative powers of these organs in disease. Another moral consideration of great weight is the necessity in all cases of making the woman clearly understand the effects of the operation on her whole life; un- doubtedly many women accept the alternative of an operation in utter ignorance of its full consequences. The especial importance of this question to unmar- ried women may be seen when we reflect that about 20 per cent, of all women do not marry, and that these are precisely the cases most likely to suffer at the hands of the unskilled surgeon. He is unable to make a clear diagnosis owing to physical obstructions, and so after a time, if the patient continues to suffer pain, he hazards a conjecture that the ovaries are dis- eased and decides that they must come out. There is another question raised by these letters which ought to be considered in the interests of pure morals, and that is, the attitude of the physician toward the prevention of the infection of wives by 7 their husbands. I know of no more distressing and pitiful sight than the pure women I often see whose lives have been wrecked by a marital infection. Just what course to pursue in the particular instance, the surgeon must determine for himself; but one convic- tion ought to rest on every man in the profession, and at all times find unhesitating expression, and that is, that there must not be a double standard of morals. What is wrong for a woman to do is wrong for a man to do. A female prostitute is as good as a male prostitute, and ought to command the same consideration and respect. This is a wise policy which looks to the future of the race, and its quick- ening influences and sound scientific results will surely be felt by our followers. If men were, as a class, as chaste as women, many of the problems of gynecology would solve themselves. With this introduction, I will now let my corre- spondents speak, only adding that I feel in entire sympathy with the spirit of the letters. LETTER I. The operation of ovariotomy has two aspects, the ethical and the medical, both of which, I think, are likely to be lost sight of by the ambitious young surgeon who sums up the whole matter so cavalierly, “recovery uneventful.” On the ethical side, an uneventful recovery may mean for the woman a life of unhappiness, and it is an open question whether the sum total of uneventful recoveries does not increase immorality among men. The function of menstruation is a natural process most inti- mately associated with the highest and holiest feelings of womanhood. Most women rejoice in potential motherhood, and, when the time comes, gladly take their lives in their hands to accomplish it. I have personally known no exceptions to this rule, except those unfortunate women who were married to sensual and brutal husbands. A sensible woman wants to be well, to keep all the organs of her body in good condition, so as to perform all the duties of life. One of the most important of these, and precisely the one that comes nearest her heart, is the bearing and rearing of children. Now, the operation of ovariotomy places the marriage relation distinctly on a lower plane, and I am surprised to have seen this view expressed but once, even by the conservative surgeons. The grossness of the physical union in marriage is redeemed by its moral significance, 8 the desire for children. This desire is stronger in women than in men, so strong that when I consider all the suffering of women in all the ages of the world for it, lam appalled. Think for one moment what women have endured, from the brutality of men, from the ignorance and blunders of medical science, from a pitiless and degrading theology that denominates the pangs of maternity, “the curse of Eve.” Men want children, too, but they do not care so much about them as women do, they do not make sacrifices for them half so willingly. The existence of prostitution shows the difference between men and women as to the sexual instinct when the hope of children does not enter into it. Women prostitutes are almost wholly from the working-classes; they are often ignorant country girls who have first been betrayed, and who are then forced to live in shame, because the hard economic conditions of life for women prevent them from gaining an honest liveli- hood. An English barrister working among the poor of Lon- don estimated last winter that 20,000 prostitutes in London world gladly give up the calling, if they could find reputable employment. And a late utterance from one of the physicians on Blackwell’s Island, New York, is, that the most practical means of meeting the social evil is to open up avenues of em. ployment for women. Men prostitutes, on the other hand, are from every class, and pay; they do not debase themselves for the means to live. It is unhappily too true that a great many men have no notion of endearment or of shame in the sexual life, and this difference between men and women bears upon the operation of ovariotomy in two ways. In the first place, it is morally indefensible to mutilate the wife for the sins committed by the husband before marriage. It adds frightfully to the physical disabilities of women, and it is a positive encouragement of vice. Every physician knows how many pure women fall victims to their husbands in this way, and it is the duty of every reputable physician to the commu- nity he lives in to discourage ovariotomy, except for most urgent reasons. “The wages of sin is death,” and one way to enforce this wholesome doctrine upon unchaste men is to leave them with ailing wives. This may seem hard on the women, but it is by no means proved that ovariotomy has not more ills in its train than good. On general principles, a woman is better off mentally, morally, and physically, if menstruation is allowed to run its natural course. As to the husbands who are respecters of persons, and who remain true to their wives made sterile in this way, their lot is a hard one. Ido not believe it is possible for a husband to love his wife as is her due knowing that she is physically in- capable of becoming the mother of his children. And no wife can live so intimately without recognizing a difference, so that in addition to her woman’s sorrow in childlessness, she is made to feel herself hopelessly outside of her husband’s feelings. In 9 mutilating her the surgeon may have made her as hateful to her husband’s sight, as if she had some frightful physical blemish. How much unsexing women may have to do with in- creasing immorality among men, I have no means of judging, but the popularity of ovariotomy and the propensities of men make the situation serious enough for the conscientious sur- geon. Nor do I know what the ultimate effect of removing the ovaries is upon the woman’s sexual feelings. Dr. Goodell thought at first it made no difference, but came to change his views. Many able physicians agree with him that the opera- tion deadens the sexual sense. This is just one of the points that gynecology must clear up. It is certainly an unusual man who marries a castrated woman. Moreover, marriage based on sense, like marriage without love, is practically a life of unchastity. This feeling dominates every woman who declines to marry a man because she can not love him as a wife should. She is unwilling to live a life of legalized prostitution, which is in plain terms simply what a great many marriages are. So far 1 have spoken only of the castration of married women, but I think the operation is even more unjustifiable when per- formed on a single woman, and should never be resorted to except when it is a choice between castration and death. To remove a young woman’s ovaries or womb and then to tell her that she is incapable of marriage physically is a barbarous cruelty. Ethically, in mutilating a virgin in this way, the surgeon may have taken from her all chance of happiness on earth, and even her hope of heaven. Economically, as the world is Constructed, many women have no other prospect in life than marriage. Besides, unless a woman has means, or education, or unusual strength of character, a single life is in- supportable. And, I take it, these are not the qualities that are oftenest met with in the gynecologic wards of our hospitals. On the medical side Dr. Lusk puts the case much better than I can. Ovariotomy is not a cure ; it is a makeshift, and in so far is a confession of weakness. Moreover, while aseptic sur- gery is undoubtedly a great advance on the old methods, it is not difficult to acquire. It is vastly easier to cut out a woman’s womb than to make and keep it a healthy organ. And this is precisely the problem that is before gynecology as a science. It must first find out a way to produce a race of women with healthy generative organs, and second, it must learn how to keep all this delicate machinery in order under the immense strain of function put upon it. In many instances I believe the world would be better off if these ambitious young surgeons were put to their books. We need better trained general prac- titioners, not more men who can perform abdominal surgery successfully. Now gynecology is a brilliant specialty, it offers great re- wards in reputation and is money. A great many young men of all grades of intelligence and morals, are rushing into it. 10 Naturally, they look to you as their exemplar, for your success in it has been exceptional. This is why I urge the matter upon your attention. I think your responsibility is very great. Per- sonally, my trust in your good judgment and your heart is ab- solute, but these are unknown qualities in the young gynecolo- gists who are following in your footsteps. Every day all over the land women are being mutilated at the hands of ambitious young men who are anxious to report to the profession that they can do ovariotomy or hysterectomy. I feel sure that not a few of these helpless victims might be saved present pain and future misery by a word of warning from you. LETTER 11. You know that I feel and have felt very strongly on the sub- ject of your letter. The time has been when to express such views as you express would condemn one to charges of “old fogyism ’’ or ignorance. But ever since the rage for ovariotomy took possession of the medical mind, I have had an invincible repugnance to the castration of women, and have often had hard work to restrain myself when statistics “of 100 cases without a death,” “my first year’s work in ovariotomy,” etc., were read ad nauseam before our Medical Society. I shall never forget the night when one of our “best operators” handed round on a plate the two ovaries of a woman recently castrated ; one had a small cystic tumor about the size of an apple, while in the other the cyst was not larger than a marble. The reporter dilated on the physical perfection of the woman, on the fact that she was about to be married, and then told of his successful operation. Just think of it! And is not this gynecology in its infancy, when to cure a minute cyst or to prevent its growth, the whole womanhood, the whole happi- ness and all the life of this woman were irretrievably ruined? And yet no one there said one word of disapproval, but all sat and admired the skill of this destroyer of everything that makes a woman’s life worth living. A wedding took place here this spring between a recently castrated girl and a young man who had been engaged to her for a long time. Do you not think that he would rather have married her with one ovary left, even if there were a proba- bility of ill health and suffering? The girl, from being slender and young looking, in six months had grown stout and much older and was by no means improved in appearance. This is all but a prelude to saying how much pleased I was at the way you presented your case against the operation. I agree with you that ovariotomy, before or after marriage, ruins a woman in all the essentials of womanhood. It makes of mar- riage just what you say. Just think of the feeling which a man must have when he marries a mutilated woman ! What does he marry for? There can be no hope and no happiness in such a 11 union; there is no end to look forward to; there is nothing which makes marriage perfect and holy. I wish your views could be brought to the inner conscious- ness of the gynecologists of the country. I wish they could be made to see and feel; but I fear many of them will think your opinions beyond the domain of science and practice and will pass them by. And then it touches the pockets. Ovariotomies are a source of income; many have grown rich on them and you strike at the root of a very thriving industry. But you should not drop your task for all this, and the fact that Dr. Kelly sympathizes with your efforts should encourage you to say and to do something to stem the torrent of mutilation.