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WEBSTER, N.Y. 14580
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^(; st'cain/i," as they call it, and make a sentimental
appeal to the principles of the citizen. " You needlessly mutilate
your patients," they say; "you castrate without reason the
women who seek your advice, and who certainly would be cured
with time, patience, and less radical means. You make too little
of such important organs as the uterus, the ovaries ; and at that
rate, in making such hecatomb of the reproductive organs, you
will soon have reduced to its minimum the population of tiie whole
woild."
Indeed — I do not deny it — abuses are committed. The stuily
of new questions is always suiroundeil with danger, and it is very
difllcult never to make a false step. We must confess, also, that
the impunity which antisepsis confers to operators sometimes con-
ceals a certain number of unnecessary surgical proc dures. But
do these few unavoidable eriois — ami which ceitainlyare to be
deploied — entitle anybody to generalize and to render the prudent
and enlightened suigeon liable to these undeseived repioaches?
If a ceitain number of patients have been wrongly operated upon
by suigeons in too great a huiiy to resort .o ilie knife, how much
more nunieious aie not the women whom an untimely reserve on
the part of the suigeon allows to die or to lead a miserable exist-
ence !
The accusation which is caiessed with the gieatest piedilection
Z. Covleux Pn'vfls/, M.D.
ii that we mutilate women and render tliem sterile. In the gteat-
est number of cases tliis aitjunient is simply lidiculous. Tlie sup-
pression of the ovaries at an age wiieie it constitutes a real sacri-
fice is inexcusable if it is not necessary ; but does the fact of
operatinjif upon women at the epoch of menopause or already
mutilated by purulent or parenchy.natous bilateral lesion render
us worse citizens ? To extirpate a uterus and not to find the
alterations we had forer^een is always an error, but it is far from
being a crime toward mankind ; and to add up the figures of sev-
eral surgeons and exclaim, " What a number of women lost for
reproduction !" is great ingenuousness, if not simply a bad joke.
No ! I confess that we are exposed to commit some errors, but one
must not exaggerate their frequency nor their importance. In
every conflagration the fire claims its share. I do not pretend
that in gyna'cology, more than elsewhere, we have reached the
ideal. I am (|uite willing to believe that the modern surgeon does
not, properly speaking, solve the problems he meets with. In re-
moving a diseased organ he cuts off the Gordian knot, instead of
untying it ; but while waiting until the philosopher's stone has
been found in pathology, you must admit that very often the sur-
geon is compelled to act radically ; and if some operators have
compromised hysterectomy by indiscriminately resorting to it, a
wise and intelligent intervention has rendered the most eminent
services to hirmanity.
Hysterectomy is indicated against the diseases which threaten
life or against those whi,-:h lender existence miserable by the
perpetual sufferings which tliey cause to the patients. Among
the former' are cancer, pelvic suppuration, and the large tumors of
the irtenrs. With regard to the malignant affections, no discussion ;
there is no other hope than complete ami early removal of the irter-
us. Hut here, general practitioners, yoir have an important lo/c to
play. It is upon you that, most of the time, depends the etlrcacy
or the faiUiie of the specialist's intervention. In fact, the indis-
pensable condition of genuine success consists in an early opera-
tion. Birt it is not always an easy matter to diagnose irterine can-
cer at its beginrriug ; and how many women have been irremedi-
ably lost for having been tamponed, cauterized, and dorrched for
pretended ulceration of the os !
Therefor'e, in all sirspicious cases do not hesitate to have re-
coirrse to competent advice in 'he matter, and do not wait irntil a
fuetid dischaige, metroi i hagia, and pain have demonstratetl that
On Hysterectomy. 5
yoii liave lust piecious time and that tlic lite ol yuiii patient is
latally cdiiipioniised.
I said tiiat in extensive pelvic suppuration hysterectomy was
also indicated. In order to render this proposition mure accept-
able, which pel haps you may deem exajxi^erated, I want to ask you,
at first, of what utility may the uterus be to a woman when the
appendaijes on eitlier side have been destroyed? All the oiijans
of the human body liave their impoitance /// .w, it is true, but we
must acknovvledife that a jjjreat number of them lose all their use-
fulness when once they are tleprived of the satellites with which
they are conjoined. The uteius contains important blood vessels,
it constitutes a considera!)le link in the lymphatic chain, it is situ
ated on the road of the greatest reflex pheno.nena ; anatomically,
we must grant to it a primordial importance ; but, you must admit
all the same, that the old axiom " Propter soliini utt'iuin mtilicr t-^t id
t/iiod est" has lost nowadays a good deal of its truthfulness, and
the uterus deserves to occupy a place among the stars of great
magnitude only owing to the physiological ro/e that it is called
upon to play in the functions of repioduction ; and the conse-
cjuence of this ro/e fades away as soon as the organs of generation
have lost partially or totally their integrity. Therefore, when
once the appendagts have been destroyed by disease or removed
by the surgeon, to leave the uterus behind, under the pietence <)f
doing conservative surgeiy, constitutes at least a grave impru-
dence when it is not an immediate peril. All the more when,
besides the appendages, the uterus itself is diseased. And who
can vouch for the integrity of the uterus in cases of pelvic suppu-
ration ? Is not the uterus the starting point of the pathological
disorders in the majority of cases of pyosalpinx ? The gonococcus,
the ordinary agent of these lesions, deflours all it touches in an
irreparable manner, and the uterus itself is not free from that
law. The strength of this aigument, which seems to me indis-
p.itablf, is far fiom being universally recognized, however, and this
(piestion is, moreover, that which is most intensely disputed among
gynaecologists. It has become the object of a sort of international
discussion. This intellectual war has for its participants the
Americans on one side and the F'lench on the other, but each
caiup possesses adherents on the adverse side. Our grandchildren
only, 1 suppose, will witness the general agreement, when time
and experience shall have demonstrated wherein I'es the truth.
Waiting for the pereinptoiy solution of this problem, if I am al-
£. C'y-/t« /''•'*''»'■ ^'■"■
clearing aw.i> I'lc i -r.catei ; we ^v'^ ^ "^-
';:;tl>. operation -"f ;;;:'„, '"^.es.ion .en.e. lUe n-e--
IperaUve tcchnicue -»^^ "^'^ ;:,„; „„a often const,.;, =•>
clanger. 1 mea ^_^ ^^j ^„„e "fl^V '^ . ,,j „,„ an
Anv iherapeuU= agetu mtlnencc up
" P"' "" ";".:,:.,: uX,aUe and often nnbea.aU,..
existence, yet render
On I/vslrrec/omv.
\
category aie included incoetciblc mdiorrliajjias, eld pareiicliyma-
tous metritis, epilepsy, hysteria, and, al)()ve all, pelvic nt-iiralj^ias.
Out oi this enuincration, I want to make some restriction, how-
ever, concerninif epilepsy, hysteria, and ntnirasthenia, aufainst
which hystert'ctoniy has not l)een fcjilowed with as brilliant results
as were expected. Nervous women constitute the opprobrium of
great surgical procedures, and it is in the treatment of these varied
pathological disorders that the gyn£ccologist is compclItMl to lay
aside his s])(.'cialist's spectacles aiul to call upon his knowledge of
general pathology, Much tact and experience is required to seize
the true nature of these deceptive grounds, and it is heie, more
than ever, that we must not treat a i/istursr, but a ['aticiit, l»(\:ause
tlierajieutic results vary from one organism to the other even when
the same local indication is fullilled. This reserve being made, it
is nevertheless a known fact that hysterectomy ha« to its credit re-
markable and defiriilive cures, even when no material lesions what-
ever could have been detected in patients tormented by unmerci-
ful neuroses or almost uid)earable pelvic neuralgias. Naturally in
these cases the opportunity of so serious an operation is cpiite
opened to discussion : still we must not disclaim all value to facts
the evidence of which very often upset the most specious argu-
ments. To arrive at a practical conclusion, a patient being given
with whom, as it so often occurs, everything has failed, a woman
who for years has been gorgeil with cod liver oil, iron, hydto-
therapy, and all sorts of antispasmodics, especially if her poveity
does not allow her to continue these therapeutic measuics, as ruin-
ous as they are stetile, I vvoidd not hesitate a moment to take the
knife and suppress at once what the expeiience ot otheis has taugiit
me to be in many cases the source of all evil.
What are the conditions required for all hysterectomy to be
successful ? Heie, gentlemen, I will be short ; these conditions
you know them ail. They are those which are in conformity with
the exigencies of modern surgery. To obtain peifect results (and
such must be the aim of every surgeon) it is necessary to operate
in a special establishment situated in irreproachable hygienic con-
ditions and under the supeiintendence of intelligent and well-
trained nurses. I am well awaie of the fact thai many operatois
do not hesitate to do these operations at the patient's own house ;
but if they can do otherwise they are wror-^, in my humble opin-
ion, not to put all the chances on their side. I know by experi-
8
/. Cqr/eux Pn'vos/, M.D.
ciiCL* tlie dett'Slahk' consctiiiciiCL's of a deftclive service, and any
amount of jjood will docs not sullice to jjive the patli-nt the stcu-
rity siie is L-ntiilcd to. I piaciisrd abdominal siirj^cry both in
mote or less wrll-tMjuippcd iiospitals and in a private estal)lisli-
ment. I will spare you the annoyance of listening to statistics,
but siitlicc! il to say thai I never expel ienced in my private institu-
tion the deceptions I so often met witli in the hospital. No, it is
useless to delude ourselves, the perfection of the surijeon's work
itself is not the only condition of success ; ipiite as imi)ortant is
the lU'cessity of cnnlidinjjf the patient operated upon to a learned
nurse, who, as it were, is the surgeon's lieutenant. In my opinion
the ideal in the healinj.j art sliouid l)e for the surijcon to have l)ut
a sinjifle patient and to remain with him all the time. This is im-
possible, as you ea..ily understand ; then teach your nurses, see
that they areas interested as yourself in your work, inyixiraj)-
prehensions, in your hopes ; let them strive as much as "ou do to
achieve the j^ood results you are wisliiiijj^ for ; let that sli eiuious
coadjutor constantly watch at the bedside of the jiatient ; impress
noon her the necessity of faithfully recordinpj all that you must
necessarily know, and you may be sure beforehand that all your
orders will oe scrupulously fulfilled.
And what about the tools rctpiired for the operation ? Noth-
ing shoidd be s|)are(l to be supplied with the most perfect instru-
ments possible. I do not mean that a complicated armamenta-
rium is indispensable ; simplicity everywhere is a virtue ; but one
must have all that is necessary at his disposal and never be caught
unawares. It is simply absurd to voluntarily create dilliculties in
the performance of an ojieration in the course of which so many
unforeseen accidents may arise.
Thirdly, we must be aseptic. Here is, though, a sine qua iion
condition. Call it asepsis, antisepsis, or otherwise, we must be
scrupulously, surgically, absolutely clean. The precautions which
must be taken to be considered irreproachable and complete re-
quire cpiite a long experience, but when once these habits are ac-
quired, there is nothing diflicult or complicated in it. everything
is instinctively done without the st omission and naturally.
At last, gentlemen, in order to icceed in this operation, which
may seem to you quite easy when you see it performed by a skil-
ful surgeon, but which is surrounded with the greatest difficulties
for whomever attempts to do it for the first time, it is indis-
pensable to possess perfect anatomical knowledge, and to have
On Hvsterectimiv.
acf|iiire(! hy study iin'l prarticir a ihnroiijjh siirjjjical «'xpt*tiLMice.
It is lU'tessaiy to liavc lu'(|iit'ntc(l tlio 1 ij^c liosjiit.ils, to have
seen tlu' masicis at work, to keep stoii'il in some corner of the
memory the varied nutlinds peculiar to cacli operator in orih-r
to possess multiple resouices to overcome iinfi)reseen dillicullies.
He who, knife in hand, vciitnies in tin- ahdomen of a woman
without liaviny; tried to ohtain the (jualilies necessaiy to peifoiin
an opeiation of that kind, is, to my mind, a veiy ffnilly one. lie
holds in his hands the palienl's life ; and if hv ( liance death docs
not follow the opeialion, it will peihaps be at the expense of an
irrejiarahle inlliniity. It does not sullice to ^o ihioutjh the woik
and not kill the patient, one must besides lelieve her sul'fei injj;s,
or at least not leave her in a wars'? situation than befoie, " pn'mo
lion noit'/c.
Will you allow me to tell you now what results we obtain by
hysteiectnmy ? What are. at liist, the immediate and then the
remote results of the opeiation? Willi leu^aid to the immediate
results, we must ajifain make a distinction according as the cases
for which we operate are complicated or not. TIk? results which
follow non complicated cases arc sim|;rfat advantages the life of the patients. But the
other laparotomists, are they right ? Those, for instance, who
claim that the abdomen should be cut open, the adhesions separat-
e 1, till- puridi-nt sacs removed, but the uterus left /// sitttf " It is
not diseased," they say ; " it does no harm ; and this," ihey add,
"cannot be done when the jnirulent collet tions are treated through
the vagina, heciiuse when once engaji^ed that way the surgeon must
go to the end and remove the uterus, wliich procedure is a useless
mutilation." They contend, moreover, that the purulent sacs
themselves cannot be entirely extirpated in many cases, owing to
the o;-erator being unable to see what he is doing, wliereas, with
the Treiulelenberg position, the laparotomist operates all the time
under the ccuitrtd of sight.
To this the vaginal hysterectomists answer thus : " If you leave
the uterus behind after having removed the appendages destroyed
by sujipuration, you do an incomplete operation, and you are ex-
posing your patient to further sufferings, as the fact has often been
demonstrated by patients upon whom we have been compelled to
perform a secondary vaginal hysterectomy to relieve the symptoms,
which continued in spite of the laparotomy they had undergone ;"
and again, they add, " You are mistaken in pretending that we are
doing blind work in operating liy the vagina ; in the majority of
cases, owing t(^ certain artifices of technique, we see very well
what we are doing. It occurs, it is true, in certain cases, that we
cannot succeed in extirpating everything ; but does not the same
thing happi n the laparotomist who many times has failed also to
remove diseased tissues held on by adhesions which it wouki have
been impossible and dangerous to sever entirely ? And in both
cases these operations that yc.u call incom|)lete do nevertheless
end in total cure, the appendages becoming atrophied later on and
the [)atient ceasing to complain. At last vaginal hysterectomy
opens to the pus a dependent issue, and the risks of contaminating
the peritonaeum are consequently a great deal less than the re-
moval of purulent appendages without hysterectom}'' by the abdo-
men.' '
You see, gentlemen, the principal point in contest is the follow-
ing : must we, or must we not extirpate the uterus when we are
On fh'fslercctnmy, 1 5
coni[)cllecl lo remove tlu' tip|)en(liiKes dcstioyovl hy suppuration ?
Tlie (lay that all pynaiculoiifists shall become convinceil lliat, in
these cases, Uie iileius even soiiiul ceases to have an\ reason to
exist ; that it even constitutes oftentimes a menace for the future,
and that its removal is not a useless mutilation, tiial day we
shall 1)0 very near understandinj^ one another, and, to speak my
mind, vaginal hysterectomy siiall come then victorious out of the
struggle and De considered by the greatest number as the choice
opeiation in pelvic suppuration.
Gentlemen, since I have chosen hysterectomy for the subject
of my paper, may I be allowed, in terminating, lo deiacli from
my observations three cases of removal of the uterus wiiicli pre-
sented rate and unforeseen moibid phenomena, and vvlK)^e brief
report might offer some interest with legard to general surgery ?
The first is that of a woman, aged forty, exceedingly nervous,
on whom 1 exti-pated by the abdomen the uterus containing a
large fibroid. The operation, lather p'-olonged, owing to the
numerous adhesions contiacted by the tumor, nevertheless offered
nothing very remarkable. It was followed by no unusual symp-
toms, with the exception of an extreme tachycardia, against which
all the means at my disposal remained useless. The veiy day of
the opeiation the pulse reached 160 to iHo pulsations a minute.
There was no svmptom whatever of valvular affection, and pre-
viously to the operation tlie pulse beat normally. During four
weeks I kept the patient under careful observation ; never did the
pulse go down below 115, oscillating ordinarily between 120, 130,
and 140 pulsations. Caffeine, strychnine, sparteine, digitaline,
bromides, cinchona, nitro-glycerine, all remained ineffectual. I
had performed hysterectomy with extra-peritoneal peilicle, accord-
ing to Baer's method ; I made afterward several vaginal exami
nations, and never could I detect the least alteration which might
have given the explanation f>f this curious pathological symptom.
This post-operative tachycardia is not the first one that I have ob-
served in the course of my practice, and some years ago I commu-
nicated a somewhat similar case to one of the meetings of the
Bathurst and Rideau medical association. It was the case of a
woman upon whom I had performed unilateral oophorectomy I'or
a cystic ovary of tbt* fi^ljt stde* tEiuj-tfij^. th'e ^titst two days that
follovk^ed theoperattgfl?.i)dr j)nls€i/:onstgi)[ly;!fleiit J4.0, 160, iSo times
per minute, the piiUieut tiifexang ia.tUe.snean. tiju^^eiher symptoms
1 6 L. Cnv/eux Pr/'vos/, MI).
of an evidently nervous character. Hut these accidents spon-
taneously disappeared at the end of forty-eijjht hours, whereas
they still persisted with the othe' 'oman the day she left the hos-
pitpl I saw the last patient since ; she feels well, she is gradually
regaining her stren;i^th, sleeps and eats well, but the pulse is still
requent, although slower than it was during her sojourn in the hos-
pital. The last time I saw her in her own house the pulse beat
loo, it was intermittent, weak, and irregular. She said she had
noticed lately quite a considerable oedema of the inferior limbs,
but a few purgatives got rid of those dropsical symptoms.
The other patient, aged forty-five, unmarried, lual equally
undergone an abdominal hysterectomy for uterine fibroid. The
operation was easy. The wound healed up by first intention, and
the sutures were removed on the twelfth day. On the fifteenth
day, without any appreciable cause, she complained of violent head-
ache, which was somewhat relieved by antikam lia. uuri-^g the
night she was suddenly seized with right haemiplegia and aphasia ;
she died in two days. This unfortunate cerebral complication was
evidently due to embolism, exceedingly rare accident, but which
has been signalled by some observers as occurring sometimes after
great surgical traumatism of the abdomen.
The third case, at last, is that of a woman from whom I le-
moved by the vagina an enormously large uterus for parenchyma-
tous metritis. Here, again, the operation was exceptionally easy
and rapidly done. Tliis woman, a mother of several children,
three years previously had had uraemic convulsions at the end of
pregnancy. As usual, the eve of the operation the urine was
examined and proved to contain no trace of albumen whatever.
Besides, with the exception of the symptoms due to her uterine
affection, and for which she was seeking a surgical intervention,
this patient appeared to be in perfect health. Anaesthesia was
produced by ether with Clover's inhaler, according to my habit.
Was this agent the cause of what happened after the operation ?
I believe it was. At all events, from the time she was put into her
bed the kidneys were stricken with a total inhibition of their func-
tions, and during fifty-six hours she hardly passed a few drops of
urine. And still neither the bladder nor the ureters had been
wounded during the operation. Before she was taken from the
operating tabic, twc ounc'es ;of urjije h«(^l'been withdrawn by the
catheter. During^ cjljti,Q!jt;three d-i^yj tlje gfOfpil state was exceed-
ingly alarmin-gf jtiie. .vomiting inc&S3i^nt,.ai3d .the facial expression