[Reprinted from the American Gynaecological and Obstetrical Journal 
for December, 1895.] 
"IS SO-CALLED CONSERVATISM IN GYNAECOLOGY 
CONDUCIVE TO THE BEST RESULTS TO 
THE PATIENT?"* 
By E. Arnold Praeger, M. D., Los Angeles, Cal., 
Fellow of the American Association of Obstetricians and Gynecologists; 
Fellow of the Obstetrical Society of London, Eng. ; 
Professor of Gynecology in the Los Angeles Polyclinic ; 
and Gynecologist to the Free Dispensary. 
It is the universal custom aboard ship to take and correct the 
vessel's position daily at a certain hour, and the doing this does not 
in any way interfere with her progress. 
Let us suppose that on a given ship a party of men, whose occu- 
pation was navigating, but who were simply passengers on this par- 
ticular vessel, got together and openly expressed their opinion that 
the course was wrong, the position incorrect, and that danger was 
ahead for the numerous lives on board ; we can easily imagine that 
the ship's officers, without perhaps admitting that they paid any 
attention to unofficial interference, would carefully review their status 
in qno and, being satisfied that their course was unassailable, would 
let the ship proceed, knowing full well that they had taken into ac- 
count all that should be considered to bring the voyage to a success- 
ful termination, and that the information at their command was to 
them more valuable and trustworthy than all the " accumulated va- 
porings of irresponsible frivolity." 
It seems to me that without delaying unduly the progress of this 
Association (which I will compare with the ship) through the sea of 
science, and without running the risk of causing any of the more 
strictly scientific papers with which she is loaded down to be jetti- 
soned, I may make use of the few minutes at my disposal to inquire 
whether the loud and at present somewhat fashionable utterances 
that we are running on rocks, or, in other words, that we are display- 
ing recklessness in dealing with the lives committed to our care and 
* Read by title before the American Association of Obstetricians and Gynaecolo- 
gists, September 25, 1895. 
Copyright, 1895, by J. D. Emmet, M. D. 2 
E. Arnold Praeger, M. D. 
overoperating in gynaecology have any foundation in fact, or whether 
the course we are pursuing is not absolutely correct? 
Overoperating in Gynaecology formed the subject of the ad- 
dress in the Department of Gynaecology and Obstetrics at the recent 
meeting of the British Medical Association in London. From the 
stand taken by a number of the medical profession one is almost 
inclined to ask whether it is of any benefit to the world that there 
should be gynaecologists ? 
Their remarks and assertions, for which they do not produce the 
least particle of proof, would imply that gynaecology is a sort of 
illegitimate appendage of medicine, which should be choked and 
strangled out of existence as a monster which has suddenly arisen 
to unsex and destroy lovely woman, whereas in truth the science 
which deals with the diseases of women is one of the higher branches 
of surgery. 
I will grant at once that in any case in which any of these gentle- 
men, who are raising this cry are consulted, they have a right to 
express themselves as to the necessity or otherwise for operation ; but 
they have no right to condemn wholesale, and generalize without offi- 
cial information, nor must they expect that for all time they are going 
to be allowed to do all the talking. 
It is surprising that that branch of surgery which has made the 
greatest strides in the latter part of this century is the one which 
has had to endure the hardest knocks and the greatest opposition 
from the exponents of what I venture to submit is miscalled " con- 
servative surgery." 
I very much question whether " conservative " should ever have 
been placed in front of the word "surgery," for unless it is intended 
to convey a meaning of contempt for the modern practice of to-day, 
its use is tautological, for the true surgeon has always been as con- 
servative as the state of knowledge in his time has permitted him to 
be, and has as zealously opposed the sacrifice of the most minute 
portion of skin or the smallest drop of blood which could be saved 
with due regard to the interests of his patient, as did Portia when 
she laid down the law to one Shylock, who was about to insist on the 
enforcement of his bond for one pound of Christian flesh. 
Now we are told that a love of glory, the glamour of a successful 
operation, even the big fee (which these gentlemen who rejoice in the 
name of "conservatives" seem to imagine accompanies or follows 
every case), tempts the gynaecologist to ruthlessly unsex, wound, and 
even kill the poor suffering women who fly to them for sucdor, after So-called Conservatism in Gynaecology. 
3 
having in all probability spent their all with those who are declaiming 
against us and our branch of practice. 
These men are of the same race who so bitterly opposed the 
operation for removal of ovarian tumor when first it began to be 
practiced with anything like success-a condition for which they were 
then and are now powerless to suggest any other plan of treatment 
that did not consign the sufferer to a miserable and certain death. 
The principles of surgery somewhat resemble justice ; you can 
not have one system of justice for a person of a white skin and a to- 
tally different system for a person of a darker hue ; in the same way 
your principles of surgery can hardly insist on early incision of the 
finger where a felon is suspected, and deny early incision to a collec- 
tion of pus within or liable to find its way into the peritonaeum. If 
surgical principles are so elastic and make such a glaring discrimi- 
nation between different parts of the body, then I very much fear that 
our boasted science is not science. 
The charge brought against us of seeking to short-cut our way to 
fame is very wide of the mark, because the moment the people find 
out that a surgeon is what they are pleased to call " fond of the 
knife," his usefulness is likely to be seriously impaired. I know this 
to be true, most assuredly, of men located in the smaller communities, 
and from remarks overheard concerning men doing surgical work in 
the largest centers, I believe it to be equally applicable to them. 
If there are men in the profession-I do not say there are-who 
prostitute their opinion for the sake of notoriety or more material 
gain, is it not at least probable that they are to be found among the 
ranks of those who continually put themselves on record as opposed 
to the teachings of the newer pathology, and that some among these 
are trying to short circuit fame by adopting what is becoming a fash- 
ionable craze, in effect, to preach that it is better for one hundred 
suffering women to die unrelieved than that one should be relieved 
at the expense of organs which are not only useless but a source of 
danger? I have little fault to find with the following sentence, which 
I quote from the address before alluded to : " Certainly experience 
has taught much hitherto unsuspected as to what may be accom- 
plished by skillful procedure and scrupulous antiseptic precautions, 
but the enthusiasm aroused may readily be carried too far. I have 
lived long enough to see the evils of rushing on too impetuously, and 
in watching the progress of gynaecology during long periods of time, 
have witnessed the wax and wane of many enthusiasms which have 
had their day, and have had a share in bringing something like dis- 4 
E. Arnold Praeger, M. D 
credit on a department of practice which, rightly exercised, is pro- 
ductive of great good, but exercised unwisely is capable of producing 
infinite harm." 
I think no one will venture to dispute the truth of that statement ; 
but it has a very much wider application than its author perhaps 
intended. Any department of medicine rightly exercised is produc- 
tive of great good, but exercised unwisely is capable of producing 
infinite harm. 
There are also many who, without being able to boast of an ex- 
tended experience covering half a century, can say truthfully that 
they "have witnessed the wax and wane of many enthusiasms " in 
other branches of medicine besides the gynaecological-as witness 
the inflation of the rectum with sulphureted hydrogen, the injection 
of tuberculin for tuberculosis, and the much-vaunted coal-tar prod- 
ucts, of which it was at one time prophesied by " enthusiasts " that 
they would revolutionize the treatment of fevers, etc. 
Were we anxious to retaliate for the many hard knocks dealt to 
us as gynaecologists, we would not have very hard work to prove that 
as many had fallen victims to new drugs and new-fashioned theories 
in medicine, without any pathological facts to support them, as can 
be laid to the charge of the surgeon or gynaecologist; while if we were 
to take into account the sins of omission of our ultra-conservative 
friends, and attempt to count those whose lives were sacrificed to 
prejudice and might have been saved by more radical treatment in 
the hands of a surgeon, we should have such a heavy balance in our 
favor that some of our ultra-conservative critics would in all proba- 
bility look about for some other materials from which to construct 
their papers for a considerable time to come. 
Were it not for the " enthusiasts " medicine and surgery would 
not have made the rapid strides with which they are rightly credited. 
That some have allowed themselves to be carried too far is no doubt 
true, but it is only just and fair to give them credit for the best 
intentions ; they acted in accordance with their lights, and were 
groping in the dark to discover means for the relief of suffering 
humanity. 
It is right that enthusiasm should encounter mild criticism to 
keep it within bounds, but when pathology points the way to effect a 
cure, or as near a cure as our limited knowledge permits it to do, 
those who in a hasty or obstinate manner refuse to accept its teach- 
ings and neglect no opportunity of expressing their disbelief in the 
necessity for operation for the relief of dangerous conditions, such So-called Conservatism in Gyncecology. 
5 
as pus-tubes, etc., surely place themselves somewhat in the position 
of the serpent when he tempted the first woman with the assurance, 
"Ye shall not surely die." 
The writer of the address to which I have alluded speaks of 
"an ardor for stitching up rents in the cervix uteri following child- 
birth-rents which were described as producing many hitherto evils, 
and frequently conducing to the establishment of malignant disease. 
One votary of this practice boasted of having detected and operated 
on, in a short period, no fewer than three hundred or four hundred 
cases which he found in examining nine hundred women. Surely 
here was a marked illustration of the mimia ailigentia." I venture to 
ask whether this is a fair way of putting the case. We all know of a 
celebrated lithotomist and of the large number of lithotomies with 
which he is credited. Would any dare to suggest that he has been 
overoperating ? 
The reason he does so much work in this line is clearly because 
he has obtained so much proficiency in his specialty that his light can 
no longer be hidden under a bushel, and patients flock to him. 
This argument might be extended to several others in many 
branches of practice, against none of whom has the charge of over- 
operating even been hinted, and I ask whether it should not be held 
in the case of the gynaecologist referred to in my quotation, in a simi- 
lar way, that he is a man possessed of skill and a large clientele, cer- 
tainly until the contrary is proved, rather than he should be branded 
as a man who is operating needlessly and thus held up as the type of 
what constitutes the gynaecologist ? 
Lest some suppose that I am attaching too much importance to 
the views of one man, I wish to quote from an " editorial " in the 
British Medical Journal of a week later than that which published the 
address which so far has formed the subject of my text. After be- 
stowing a few complimentary remarks on the address, the article goes 
on to say, " Unfortunately, several European authorities of high repute 
continually advocate extreme courses, such as total extirpation of the 
uterus, with the appendages, in cases of chronic, or even acute, inflam- 
matory affections of the tube and ovary. Last June the German Gy- 
naecological Association met at Vienna. A leading authority laid 
down the law that in gonorrhoeal disease of the appendages it is abso- 
lutely wrong to leave the tube and ovary on one side, even if they seem 
healthy, and that it is much better to remove the uterus as well. An- 
other authority supported him on the score that many ' parenchyma- 
tous bleeding areas ' are to be found in the uterus in these cases, so he 6 
E. Arnold Praeger, M. D. 
always removes that organ. He does the same, he adds, in cases 
of malignant ovarian tumor-a clinical and pathological condition 
quite different from gonorrhoeal inflammation. Veit, of Berlin, spoke 
in a vein of satire. The advocates of amputation of the uterus insist 
that when the appendages alone are removed, exudations on the two 
pedicles set up pain and cause adhesions to the intestine, or else fix 
the uterus. Veit attributes the exudations to fresh gonorrhoeal infec- 
tion; ' therefore,' says he, ' castration of the husband is the best thing 
for the patient.' Unfortunately, in France as well as in Germany, hys- 
terectomy is extensively carried out. It is difficult to conceive any- 
thing more unsurgical than extirpation of the internal female organs 
for damage done by gonorrhoea." 
I think it will be conceded that there is a large proportion of 
cases in which in the interest of the patient's future well-being it is 
advisable when removing the ovaries and tubes to also remove the 
uterus. 
The modern method of excision of the breast demands the com- 
plete removal of the axillary glands, the fascia, and the skin beyond 
any suspicious line of infection ; and is it not probable that the same 
holds good that in removing the adnexa for malignant disease it is wise 
also to extirpate the uterus, which would otherwise, at best, be but a 
useless organ, especially when we consider that its removal adds little 
if any to the danger of the operation ? Is it not easy to understand 
also that there must be a certain number of cases in which the uterus 
is found to be so diseased (when the abdomen has in the first instance 
been opened for the extirpation of diseased appendages) as to make 
it advisable in the interest of the patient to sacrifice that also ? 
Although a great many contend that it should invariably be re- 
moved at the same time as the ovaries and tubes are, because without 
them it is a useless organ, I think it is not in accord with correct prin- 
ciples to remove an unoffending organ simply because it is useless. 
Yet, according to the British Medical Journal, this course has the ad- 
vocacy of many authorities of high repute, and therefore it should not 
receive wholesale condemnation until it is proved beyond the shadow 
of doubt that gynaecological authorities are either less educated or 
more reckless, or both, than their brethren in the other branches. 
The sentence, however, that I find hardest to reconcile with patho- 
logical fact is that containing the startling statement that '' it is diffi- 
cult to conceive anything more unsurgical than extirpation of the in- 
ternal female organs for damage done by gonorrhoea." 
When so flat-footed a statement as this is made, it appears to me So-called Conservatism in Gynaecology. 
7 
that we are entitled to ask the writer (whose views must at least coin- 
cide with those of the editorial staff, otherwise the article would not 
have been admitted as a " leader ") whether he knows anything about 
the damage to the internal female organs caused by gonorrhoea ? and 
if so, what treatment short of ablation is in the majority of cases of 
the slightest avail ? 
This is a fair sample of so-called " conservative " literature. Those 
who have had to deal with internal female organs damaged by gonor- 
rhoea know that delay here, in the largest proportion of cases, means 
death and a harvest for the undertaker. 
If the writer is aware of any plan of dealing with this terrible con- 
dition which will at the same time preserve to the patient her organs 
and her life, he should not lose time in publishing the fact, that his 
confreres will no longer be under the necessity of indulging in the 
unsurgical (?) course which he finds it so hard to understand. 
I do not wish to be understood as advocating the needless mutila- 
tion of the human or other animal; but when diseased organs threaten 
life, or place the patient in such a position that life becomes a burden, 
or prevents the performance of the necessary duties, I can imagine no 
higher privilege than that of the surgeon to remove the offending mem- 
bers and restore his patient to a condition of safety or usefulness. 
While in the greatest number of instances the best rule for guid- 
ance undoubtedly is that the least sacrifice of parts is an exhibition 
of the best surgery, in malignant disease, on the other hand, it is better 
to " cut wide of the mark." 
The removal of ovaries and tubes simply for pain, when they do 
not present pathological conditions, has for some time been con- 
demned by gynaecologists, and there is no more occasion for members 
of the general body of the profession to keep harping on that string 
than there is for the gynaecologist to keep on reminding the oph- 
thalmic surgeon that the eye is a valuable organ and should not be 
wantonly condemned simply because it is unsightly or sightless and 
no source of danger to the other eye. I imagine it would be found, 
if an exhaustive inquiry were made into the matter, that the neurotic 
cases-those in which the patient " carries her sexual apparatus on 
her brain "-do not remain in the hands of the gynaecologist after it 
becomes apparent that the sexual organs are not the seat of disease, 
but are handed over, as they should be, to the neurologist. Having 
indulged in this long introduction, let me briefly inquire what so- 
called conservatism does for the female from an early period of her 
existence. 8 
E. Arnold Praeger, M. D. 
In the first place, while it raises its voice loudly against operative 
measures having cure for their object, it appears to take no stock in 
prevention, and has done nothing to lift the veil of ignorance, mock 
modesty, or whatever you choose to call it, which covers the whole 
subject of the physiology of the sexual apparatus. 
It almost necessarily follows that the young about the time of 
puberty (if their minds have not already received the "evil communi- 
cation" which, we are told, "corrupts good manners") get anything 
but strictly trustworthy physiological facts about their functions, from 
those who neither in knowledge nor years are fit or capable to impart 
information which, properly given, would be useful, and in a great 
many instances really preventive. 
Does the young expectant mother, as a rule, receive from the 
medical practitioner the information that would be so useful to her 
during the time of her pregnancy ? 
Is it not a fact that too often she is left to obtain information 
which may or may not be trustworthy from more or less ignorant 
females, whose only qualification, as a rule, is that they have been 
through the mill ? 
How often does it happen, in spite of all that has been written 
as to the importance of repairing damage to the perinaeum immedi- 
ately after the completion of delivery, any attention is given to that 
body, on the integrity of which a woman's comfort and future well- 
being so largely depends ? 
Or if it is stitched, how much value can be attached to the man- 
ner in which it is done in too many cases; for is it not a fact that too 
often the woman gets up with only a skin perinaeum, one existing 
in name only, and, anatomically, not of the slightest practical value 
to her ? 
Then some few months or weeks after, when she complains of 
more or less backache, bearing-down pain, pelvic distress, or purulent 
discharge, how often is she submitted to strictly scientific treatment? 
Is it not of such frequency that it may almost be stated as the 
rule that she is given some supposed tonic and vaginal wash, and that 
without adequate directions as to use, and assured that as she gets 
stronger she will lose her symptoms ? 
And the last state of that woman becoming worse than first, she 
eventually does what she should have done long ago, and falls into the 
hands of a gynaecologist who restores her to society a useful member. 
The great reward bestowed on the gynaecologist is the charge of 
having operated needlessly. So-called Conservatism in Gyncecology. 
9 
While it has not been proved with mathematical accuracy that 
laceration of the cervix is the cause of cancer, is it not a fact that in 
the greater number of cases of cancer the cervix is found lacerated ? 
And may not the unhealthy tissue thereby induced be more prone to 
take on malignant degeneration ? 
Or granting, for the sake of argument, that there is no relationship 
between laceration and cancer, is there any valid reason why an injury 
of the cervix should not be repaired by suturing in precisely the same 
manner that the general surgeon would adopt in a wound of the lip, 
or forearm, or any other part of the body ? 
Why attempt to get primary union in one part of the body, and 
teach that it is wrong in another? 
What would be thought of the surgeon who took so little pains in 
approximating the edges of a wound in a woman's face that an ugly 
scar was the result ? 
Beyond the fact of the annoyance caused by the unsightly scar in 
this situation, the cicatricial tissue would not in all probability cause 
or set up any suffering ; and yet fault is found with us for trying to 
prevent a mass of scar tissue in the cervix, where it undoubtedly is 
often productive of a neurosis. 
In commencing malignancy of the uterus, does not so-called con- 
servatism in delaying operation, or in only removing a small and insig- 
nificant portion of the cervix, condemn the patient to an almost cer- 
tain recurrence and death ? True conservatism recommends the 
removal of tne whole organ early, with but little risk to life and at 
the expense of a body whose functions are already lost in conse- 
quence of the disease. 
So long as we hold fast to surgical principles and apply them to 
our gynaecological patients, I think we can make sure of keeping on 
the right track, and instead of being put on the defensive, we are en- 
titled to ask of all our critics and of all cavillers-and we shall require 
something more than mere assertions from them-" Is so-called con- 
servatism in gynaecology conducive of the best results to the patient ? "