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[Reprinted from the American Gynecological and Obstetrical Journal
for March, iSgy. Copyright, 1897, by J. D. Emmet, M.D.]

ON HYSTERECTOMY.*

By L. Coyteux Pri vOst, M.D., Ottawa, Can.

In 1874, tifver I had been invested by the learned faculty with
the light of " Secure per orbem terrain^'" and considering however
my scientific luggage insufficient to undeitake the great voyage
thiough life, I conceived the idea of going to complete my medical
studies on the other side of the Atlantic. I made up my mind to
sail at first diiectly for Ireland, in order to study gynjecology and
obstetrics. I entered, as resident pupil, the Rotunda Hospital,
which even at that time enjoyed a universal and well-deserved
reputation. Among the physicians whom I had the pleasure of
knowing in that institution I became intimately acquainted with
Fancouit Baines, the son of Robert Barnes, the gieat gynaecolo-
gist, whose name and fame aie known to you all. This excellent
ft lend, Fancourt, of whom I always kept such a sweet remem-
brance, is to-day gloriously following the footsteps of his father,
and already belongs to the brilliant phalanx of British celebrated
gynaecologists. When at the end of the summer I had to leave
Dublin for France, I would not part with Fancouit without secur-
ing the promise that he would come to Paris and spend a few days
with me. He kept his word, and came, accompanied by his ven-
erable father. During their sojourn in the great city, I tried to
make myself as agreeable as possible, and offered to take them
through the hospitals, proposing, among others, St. Louis, where
I might introduce them to Pean, whom I had the good fortune cf
knowing particularly. , This, propqsi,t.io.n vyas .eiithusiastically ac-

Read before the Ottia'.va^Jlcdtcal Sddeiy, I'J^ve.rt^bp4 r 3, 1896.

60533

Z. C(;)/fw.v PrMyst, M,D.

cepted. " Let us jj^'j to llic St. Louis,' suid Rohcil iJaniL's. "I
would love so much to see Pean temove a uterus."

Do you lieai that, g<;ntleint!n ? The gi^eat, tlie illusti ious Baines
wishhij^ t(j satisfy his curiosity, and buiniiijjf with the desire of
witiicssinjj^ a case of hystertctumy — so seiious an operation at that
e|)iich that even the uiasters in suigeiy hesitated to undertake it !

This occurred hardly Iwenly-thiee years ago, and this foiruid-
able operation, about which the same Rcbert Bar nes was sa\ ing
then that the time had not come for forming a confideirt opinion
rrpoir its piaciice, of which there was, ire said, very little groirnil for
enllursiastic advocacy ; that operation, the performance of which
was the object of a mere curiosity lo foreign surgeons coming to
Paris ; well, not a week elapses to-day without this same operation
being peifoimed once or twice in Ottawa by your most humble
and obscure servant.

Is not this fact more than srrflicient to demonstrate what won-
derful progress lias been accomplished in gynaecology within the
last qirarter of the century ?

If this meeting was composed of gynaecologists, how many im-
portant questions would I not feel tempted tcj bring before you,
and upon which I would willingly inquire into the results of your
special and personal experience ! Gynaecology, do you see, is a
comparatively young branch of sur-gical science, and the immense
development it has received within the last few years has given
rise to a gr-eat number of obscure points which are awaiting some
rays of light thrown on them by the shock of discussion, and the
control of collective experience. But you are all general practi-
tioners, my good old friends, with whom I have worked, studied,
and discirssed, dirring twenty years, subjects of general practice,
and with whom I must part, since I have come to the determina-
tion of devoting myself hereafter to special work. But although
somewhat swerving, I do not quit you altogether', and I bid no
faiewell to general pathology, whose teachings the specialist must
never forget, and from which, on the contrary, he must inces-
santly draw the principles that will guide his doings. You, my
friends, are at the crossway, at the confluence toward which all
the branches of pathology converge ; yoir, at a glance, embr'ace
all the knovtlei3cfe.*fIoJit»ii» luxjilgitt ijr'fjim-evervwhere, to make of
it a synthetitaJ/ajipJiSatrbw td thre 'httilfrtg art. We specialists,
williout ce^asjii^jr itcy Jjel3:in^ ,to thelg'/jjidra'l. Bi'Jdy, momentarily leave
it off in orji.qr Cw, tltoipughlx ex^lofd •parl'rc-ular roads. We bring

On Hyslerecloniw

hack from these excursions ditrested infotm-ition upon a spt-cial
subject, vvliicli it is oui duty to poui from time to time in tlie bosom
of our reunions, focussing, as it were, these vaiied notions, so that
eveiy one should derive benefit fiom them.

'I ills is wliat I intend to do tliis evening, gentlemen, choosing
for my sui)ject "Hysterectomy." We shall examine together,
when is the removal of the uteius indicated ; what conditions aie
requited to successfully perfcrm this serious operation ; what re-
sults we obtain by it ; and, at last, what is the best way of doing it.

Gentlemen, the poor gynaecologist has been of late the object
of very bitter criticism, and excessive descants have been made
upon the " operative delirium" with v/liich we aie supposed to be.
possessed. Thiscriticism emanates from diffeient sources ; some
of it being indulged in by those who ignoie totally what they aie
talking about, linding it easy to condemn what tiiey cannot per-
iiaps do themselves. Other is made in good faith by some sur-
geons who, in the name of conservative surgery, try to put a stop
to the "//•//'/>(; 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-

/. 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|<ly aslonishinu;. We can say
that here we may expect to hit the maik in almost every case ;
mortality lould be null ; one hundred per cent, of success oujijht
to be the statistics oi every gymccoloji^ist. The only, or the great
est danger, is septicemia. I am well aware that, owing to the
aseptic and antiseptic means at our disjiosal, we can in the major-
ity of cases prevent this deadly complication ; but, unfortunately,
it is not always |)ossil)le to be sure that a stealthy streptococcus
has not found its way to the held of operation, which it imme-
diately contaminates by its presence. The shock, according to
several gynaecologists, would not be anything else but the result
of septic accidents.

With regard to hc'cmorrhage, it is always due to faulty tech-
nique on the part of the operator, to the imperfection of the in-
stiuments, to the bad qualities of the materials emi)loyed, and must
not be put to the account of the operation itself. In surrounding
himself with necessary precautions the surgeon ought to be in a
position to avoid these dangers.

But all cases are not so simple, and certain complications
determine more or less satisfactory results according to their na-
ture. Thus, in hysterectomy for cancer of the uterus, the risk of
contamination is always imminent. And again in pelvic suppuia-

L. Coyicux Pri'vosl, M.D.

tlon, if is im|K)ssil)le to know beforeluuul tlie virulencf; of llie pus
it contains. Scplic peiitonilis in tlie latter cases is always to be
(iieaded, especially when the operation ispeiformed tiuoiii^li the
abdomen. The nioie or less abundance of the collection isheie
but of asecondaiy importance; and it lias happened to me, as
well as to other suijj^eons, to see the peritoneal cavity litei ally
flooded with pus without any notable following elevation of ttm-
peialure, wlieieas veiy (*flen the meie contact of the peiitonoeum
with a tube hardly c(»ntaininjT a few diops of pus has sufficed to
determine rapidly fatal accidents. The micioscope has given us
llie solution of lliese api)arenlly paradoxical phenomena, and we
are well aware to-day that the old purulent collections ai e ofttn
enliteiy steiile, whei eas recent acute abscesses contain an e.Kirerne-
ly ser)lic pus. The situation, the character, a-id the e.\ient of
anatomical lesions also very often aggravate the immediate prog-
nosis of hysterectomy. Thus, during tlie removal of a iibtoid, we
often meet with general or partial adhesions to the peritonaeum,
to the bowels or the bladder ; and again, in pelvic suppuration the
appendages are often blended together, forming but a vast sac the
walls of which adhere evetywheie to the surrounding parts, espe-
cially to the rectum ; and they have, as it were, to be sculptured
out of their nest. The liandling inflicted to the intestines, added
to anaesthesia, always prolonged in these cases, is very often fol-
lowed by regrettable if not fatal consequences. In spite of all
these unfavoiable conditions, the general statistics prove to be
absolutely encouraging, since hysterectomy shows but a mortality
of tvvelve to fifteen per cent, in these complicated cases, which,
left to themselves, would sooner or later surely end in the death
of the patient.

Let us see now the remote results obtained by hysteiectomy.
These results are physiological and therapeutical. The considera-
tion of the former will allow my doing justice, in a few words, to
the objections made to the operation by those whom I will call the
abstemious surgeons. What are these objections? "You emas-
culate women," they say. "You render impossible all fuither
fecundation." I already refuted this argument above, begging of
you to remember that the women upon whom we are doing hys-
terectomy are almost always sterile by the mere fact of the patho-
logical lesions for which they seek relief.

" You modify their humor, you change their cliaiacter." Yes,
by all means ; but the patients are not the losers by it, becaus";.

On Hysterectomy,

by putting an ei'.il to ilit-ir siiffi-i ings, we have removed the ihoin
which constantly iiiiUUed Llieir nervous system ami tendered liiein
unbearable to tiiemselves and to every one aioiind.

" You abolish all jj;enital feelings, and you create in them a sex-
ual fiigidity vviiicii often destroys all conjugal felicity, and con-
sequently becomes the frequent cause of domestic unhappiness."
To this gratuitous asserti'in I oppose tlie most energetic denial.
Contrarily to tliis errone ms idea, too generally sprci'.d and even
propagatf.d by some text-books of physiology, the experience of
many observers, as well as my own, has taught me that sexual ap-
petite by no means resides exclusively in the internal genital
organs. Women endowed with ardent temperament keep it after
hysterectomy, and, moreover, in certain cases it becomes exag-
gerated. I am even ac(piainted with a vvf)man who never experi-
enc( '1 any conjugal emotions until after the removal of her uterus
and her ovaries.

" You prematurely hasten menopause, with all the disagreeable
symptoms that accompany it." This I do woX. deny; after hys-
terectomy we must expect the majority of women to complain of
headaches, hot flushes to the face, etc., symptoms generally re-
lieved, though, by bhxKl-lcUting or a few doses of bromides, and
which, at all events, spontaneously disappear after a few mcnlhs.
Hut what are these inconveniences, after all, but natural, compared
to the previous dangers and sufferings ? With regard to these
vicarious manifestations, it is not without interest to remark that
Richelot and Segond have observed that their frequence and in-
tensity are a great deal less after total castration than following
simple ociphorectomy.

What therapeutical results do Vv-e obtain by hysterectomy ?

Here it is that triumph is resplendent upon the whole line !

In cancer of the womb, if the operation luis been done early,
we add two, three, four, and even eight years to the life of the
patient. After the lemoval of the uterine tu-nors all suffer ings
vanish as if by enchantment ; metrorrhagias ceasing, anaemia dis-
appears, the woman revives and regains her youthful appearance.
Same results after hysterectomy for parenchymatous metritis and
pelvic suppuration. Notliing is so consoling, in that respect, as
to pel use in detail the numerous observations published by the
French hysterectomists. The patients, seen again several years
after their operation, continue o feel m'<r\ellously well, and they
all express their satisfaciion wi; i the same words ; they emphati-

12 L. Ciiyfeux Pn'vht, M.D.

Ciilly fleclare never to have enjoyed more perfect liealtli. I cduIcI
n')t say as much concerning the other pathoh)gical disorders which
might liave detcM-mined the sntLjeon to remove the uterus — I mean
the great neuroses and pelvic neuralgias witliout anatomical
lesions. I cannot hut repeat here tlie restriction I made above,
calling again your attention, however, to the very consoling hopes
which the cases ])ublished by Richelot allow us to conceive, and
in which this surgeon has observed the most encouraging and per-
manent results.

What is the best way to remove the uterus ? Which way shall
we choose, i\\^ abdomen or the vagina ? This is where the discus-
sion warms up, and contradictory arguments pour in right and left.
The Americans stick fast to laparotomy, and surely they perform
that operation in such a clever manner, they obtain such brilliant
results that tliey are undoubtedly altogether justified in fighting
for their opinion. The French, on the other hand, would rather
operate through the vagina ; and again, at their turn, they have
become so expert that we feel in duty bound to grant the conces-
b^^ions they claim. It is needless to add that I declare myself en-
tirely incompetent to peremptorily decide the question. Besides,
the discussion is actually in all its vigor, the periodical reviews '

abound in articles on this subject. However, it seems to me that
they only debate without progressing. Both methods are perfect-
ly acceptable, and one does not exclude the other ; they both
answer special indications according to cases. The discussion,
properly speaking, does not dwell on the best way of removing
the uterus, and the problem would soon be solved if it were put |

)

in these terms : " It is necessary to extirpate the uterus ; which ||

way shall we do it?" The more or less gieat difficulty of one
method over the other must not be exclusively taken into consid-
eration. The skilful surgeon must be in a position to equally well
operate by both ways, abdominal or vaginal, whatever may be the
hardship lie is liable to encounter by one or the other proced-
ure. The important point is to minimize the risks with regard to
the patient and to choose the method which will yield the best
results in a given case. As far as the difTiculties are concerned, I
believe them to be even on both sides, and the inconveniences of
either method are equally compensated by advantages. The ob-
jections offered by the adversaries are actually puerile. " Do not
operate through the abdomen," say the vaginists, " on account of
the ugly scar that the operation leaves on the abdominal walls."

On Hysterectomy. 13

But that scar, who will see it ? Society will never permit the
women to dress low enough to show that they have been operdied
upon, and the most interested one in the whole business shall cer-
tainly find to the knowledge of this slight imperfection an ample
compensation in the privileges granted to him alone.

And what about the consecutive hernia ? Of a very unlikely
cccurrence if the sutures of the abdominal walls are carefully and
methodically made.

" Operate through the abdomen," shall the laparotomists say in
their turn. " Vou are lisking less to wound the bladder, the
ureters, and the rectum. ' Indeed I Is it sodiflicult to learn pei-
fectly the techiiioMe of vaginal hysterectomy and to avoid these ele
mentary errors ?

In one word, is the question to remi ve the uterus merely
and simply in a case devoid of all complu alions ; choose the
way you like, the difficulties and the advantages are.etpial lu
i)Oth sides. But where the discussion becomes imporiant is in tlie
treatment of tumors or pelvic suppuration. I pass over silently
the cancerous uterus which some operators seem to have a ten-
dency of late to remr;ve by ihe abdomen as advised by I*i Ik, Kelly,
and Pryor ; observations on iliis subject are too few to allow our
forming an opinion one way ( 1 the other. But with rcgar.i to the
fibrous or other uterine tumors, the size of the growth constitutes
the important point. However, even for small tumors, an. I what-
ever may be the results claimed by the v;'gi. lists, I fiankly confess
my predilection for the abdominal route. The dangers of the
operation are hardly more considerable ; and to a surgeon used to
operate both ways, abdominal hysterectomy will require less time
to be performed than the morccllation of the tumor by the vagina.

But when we have to deal with pelvic suppuration there the
trouble begins. The question here is no more to know which is
best way to remove the uterus ; on the contrary, gynaecologists
are divided in two camps, exactly like our politicians ; we have
the conservatives and the liberals. Which is the best policy ? To
open the abdomen, evacuate the purulent collections, remove the
diseased appendages, and leave the uterus in its place ? Such is
the opinion of the laparotomists — the conservatives. Or is it more
advantageous to burst open the vagina, allow the pus to flow out,
extirpate by that route the purulent sacs and sacrifice in the
mean time the uterus, as advocated by the vaginal hysterectomists
— the liberals ? I know that a certain number of gynaecologists

14 /. Cor/fiux Pn'vfisI, M.D.

exists who, in every case of pelvic su|i|)uration, l)clieve in the
necessity of always removing the uterus with the ajipendajj^es, and
who prefer doing the operation by the abdomen rather than by
the va,u;ina. These I deem to be absolutely wronjj ; they jeopard-
ize without j>;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