A PROBLEM IN ABDOMINAL SURGERY: WHY 
IS THE UTERUS RETAINED AFTER THE 
OVARIES ARE REMOVED? 
BY 
HARRIS A. SLOCUM, M.D., 
PROFESSOR OF GYNECOLOGY IN THE PHILApELPHIA POLYCLINIC. 
EROM 
THE MEDICAL NEWS, 
October 7,1893. [Reprinted from The Medical News, October 7, 1893.} 
4 PROBLEM IN ABDOMINAL SURGERY: WHY 
IS THE UTERUS RETAINED AFTER THE 
OVARIES ARE REMOVED? 
By HARRIS A. SLOCUM, M.D., 
PROFESSOR OF GYNECOLOGY IN THE PHILADELPHIA POLYCLINIC. 
This question may at first seem to be a startling 
one and to savor of that ultra-radicalism which the 
more evenly-balanced minds in the medical pro- 
fession are constrained to avoid, but a careful con- 
sideration of the facts that have been presented to 
my observation have led me, at least, to the con- 
clusion that such is not the case ; that, on the con- 
trary, there are several good reasons for propound- 
ing such a query, and that our patients may be 
benefited in the future if we will take steps to 
inform ourselves upon such points bear as directly 
upon the subject. 
This suggestion has been reached by observing 
the large number of women who have continued to 
suffer after the removal of the ovaries. On close 
questioning their pains are found to be just, or 
nearly, the same as before the operation. Sometimes 
they are described as being even worse, and, although 
we should use great discrimination in accepting the 
statements of a patient who considers herself to 
have been badly treated, yet I am sure that such 2 
suffering as remains is positive and great, while 
allowing for all exaggeration, conscious or uncon- 
scious, on the woman's part. 
Having been assured by the operator, and honestly 
no doubt, that they would certainly be cured and 
freed from pain if they would consent to an operation, 
these women have submitted to it hopefully as the 
last thing to be done after weary months or years of 
treatment, and have too often failed to obtain the 
expected relief within varying periods of from six 
months to three years. These patients wander from 
one physician to another, and from hospital to hospi- 
tal, with their pains not only unrelieved but gradu- 
ally losing hope of relief; and as a rule, the physicians 
themselves, having learned that an abdominal sec- 
tion has been performed and the ovaries removed, 
yet the sufferings are just as severe, are often at a 
loss as to what should be done, and mentally con- 
sign the case to the class of "incurables," while 
they are writing a tentative prescription to afford 
relief for a time at least. 
Continued suffering after removal of the append- 
ages may depend upon a number of causes, and it is 
distinctly not claimed in this article that hysterec- 
tomy will prevent or remove them all, but, if per- 
formed under the conditions to be mentioned, I 
believe that it will certainly prove a legitimate and 
satisfactory method of dealing with one of the com- 
mon sources of pain to the patient and disappoint- 
ment to the surgeon. 
Before determining upon the utility of the meas- 
ure indicated in the title, a brief consideration is 
required of antecedent matters, the proper under- 3 
standing of which will greatly influence us in form- 
ing our opinion regarding it. 
First, as regards the physiologic relation of the 
uterus (and its appendages) to the body. The geni- 
tal organism, considered in respect to the individual, 
is not at all essential to that individual's life. It is 
a specialized department designed for the purpose 
of continuing the species, and is not a vital part in 
itself. The function of the ovary is to to form the 
ovum; the raison d' etre of the uterus is to receive 
and nourish the fecundated ovum; and menstrua- 
tion is but a side-issue-the removal of furniture for 
a tenant that was not prepared to remain. 
These organs contribute nothing to the mainte- 
nance of the body, and their removal, if not for- 
bidden by danger to contiguous parts, evidently 
cannot affect the general nutrition, interfere with 
self-support, or lessen the powers of resistance to 
adverse influences. 
To their tremendous importance as factors in 
influencing the moral life of an individual, and the 
latent influences that they exert over her equili- 
bration and well-being, is given full recognition 
and acknowledgment; but these phases are not 
now under consideration, our only object at pres- 
ent being to determine upon the relative value of 
the procreative system as a vital part, or as neces- 
sary to the existence of the body. 
Much testimony from various sources might be 
adduced to show the relative unimportance of the 
genital system per se to the general organism, 
but every physiologist will recognize this; and the 
physician, when recalling that we are dealing with a 4 
diseased and perverted system, will hardly fail to 
do the same. 
The dominant nerve-supply of the uterus is that 
of the sympathetic, but it is probably of direct and 
physiologic use only during pregnancy, because the 
unimpregnated uterus is really an immature organ, 
and doubtless the nerve-fibers and ganglia are 
equally immature, so far as a correct performance 
of their duties is concerned, and this imperfect 
nerve-action may largely account for the predomi- 
nance of the so-called hysterical element in women. 
It may be presented, in rebuttal, that pregnancy, 
when the nerves are developed, often causes still 
greater abnormal developments of mentality; but we 
should remember the artificial surroundings and ac- 
companiments of the majority of gestations in civil- 
ized life, and the vast number of pregnancies that 
have for years been preceded by symptoms of ute- 
rine disease, permitting the inference that the mus- 
cular home of the fetus is in an imperfect condition 
for its work from the very beginning. 
A complete knowledge of the power that this 
nerve-supply to the uterus exercises over the body 
in a healthy woman has not yet been demonstrated, 
but the untoward effects when these nerve-endings 
are disturbed are often manifest, and many cases in 
my experience present evidence that such disturb- 
ance exists in a large number of those who have 
already had their tubes and ovaries removed. 
Let it be remembered that in the greater number 
of cases in the class to which I refer, inflammation 
has established itself not only in the tubes, but also 
in the lining membrane of the uterus, and in the 5 
canal tunnelling the uterus and leading to the 
tubes. * 
In the hands of the advanced operator of to-day 
this fact is recognized, and an effort is made to meet it. 
The uterus is curetted and drained and the appendages 
are subsequently removed, but the tunnel cannot be 
reached, and it remains to form a perpetual point 
of departure for subsequent attacks of endometritis, 
extending to an organ which is as disposed as ever to 
participate in such inflammation, whose nerve-supply 
is ever ready to indiscriminately affect the body 
adversely, causing the old pains and added reflexes, 
and which is yet deprived forever of its functions. 
It is like an eye that cannot see, yet would bring 
about all the untoward results of a vicious refraction; 
like an ear that can no longer hear, yet tortures the 
body with vertigo and tinnitus; or like a brain that 
can no longer direct, yet brings to bear upon the 
body all the vagaries and illusions of an undeveloped 
or imperfect center. 
The next question is: Would the removal of the 
uterus add to the mortality? Practical experience 
in this direction shows that the length of the opera- 
tion is not greatly increased. If an operator begins 
an abdominal section with the direct intention of 
removing uterus and appendages, after having ascer- 
tained that the latter are irretrievably diseased, the 
application of another ligature to each uterine artery, 
the separation of the bladder from the uterus, and the 
severing of the latter according to Baer's method, 
with the subsequent attention to peritoneum and cer- 
vix, would take from ten to fifteen minutes. So much 
for the time. The testimony of many writers is to 6 
the effect that they are surprised at the small amount 
of shock sustained by their cases of hysterectomy. 
In the records of English and American journals, at 
the hands of many of my confreres and in my own 
experience, the same holds true. 
It seems to shock the patient less to remove the 
uterus with its appendages than to remove the latter 
alone, and I think the explanation lies in the fact 
that we at the same time remove the terminal nerve- 
filaments of the inferior hypogastric plexus of the 
sympathetic; that is to say, the active, working ex- 
tremity of the nerve. A moment's consideration 
will recall the difference in receptivity to impres- 
sions between that possessed by the sensitive, devel- 
oped nerve-ending and its trunk. A ray of light 
falling on an inflamed retina might cause agony, yet 
the cut end of the optic nerve might be exposed to ten 
times the amount without recognizing its existence. 
Without doubt, the time required in operation is 
not greatly increased, while the subsequent shock 
appears to be really lessened. 
Another danger that threatens is hemorrhage. In 
a paper read at the last meeting of the American 
Gynecological Association several deaths were re- 
ported from hemorrhage caused by slipping of the 
ligature, but one acquainted with the correct method 
of performing Baer's operation will readily see that 
if this is carried out as it should be, such a thing 
would be practically impossible, as the ligatures 
have tissue on both sides and cannot slip; they 
may become untied, and so might any ligature. 
Sepsis from the cervical canal, again, when the 
operation is rightly performed, is unknown to me. 7 
Reasoning from a knowledge of the condition of 
the tissues in the different parts, one would expect 
to have less danger from sepsis than if the cut ends 
of the tubes are presented to the peritoneum, for 
these are the very parts in which the disease is pro- 
nounced, while the cervix is generally healthy and 
would be far less likely to contain germs, and would, 
moreover, act as a far better drain than the occluded 
stump of tube and cavity of the uterus. When the 
uterus, tubes, and ovaries are removed en masse the 
infected cavity is not opened, the pus is sealed off 
in the upper part and cannot come in contact with 
the tissues. 
Undoubtedly oophorectomy has been performed, 
in many cases with subsequent cures, and my propo- 
sition is presented neither to disparage previous 
attainments, nor as a measure to be followed in- 
discriminately and without judgment, but because 
my experience with hospital and dispensary post- 
operative sufferers has led me to inquire into the 
causes of their sufferings, and I find that although 
some of these are due to adhesions, fistulse, and 
hernias, the principal source of trouble is the per- 
sistence of a chronic metritis or endometritis, almost 
always involving the cornua, inaccessible, and prac- 
tically incurable. 
My proposition, therefore, is that we should con- 
sider the propriety of removing the uterus, as well as 
the appendages, in those cases in which both ovaries 
and both tubes are diseased beyond repair, and 
when their removal is clearly indicated; inasmuch 
as the uterus, if retained, is not only absolutely use- 
less, but often becomes a menace to the system. 8 
This measure has been advocated by other writers. 
Since beginning this paper my attention has been 
called to a statement made by Dr. B. F. Baer in an 
article in the New \ork Journal of Gynecology and 
Obstetrics for September, 1893 > but my opinion has 
been reached almost entirely through my own 
observation. 
I have said that this measure is not to be fol- 
lowed indiscriminately and without judgment. 
Cases will present themselves in which it would be 
unwise to carry it out, and each operator must ex- 
ercise his judgment with each case ; but the general 
proposition holds true, and one need but hear the 
symptoms and examine the tender, enlarged uterus 
in these barren patients to feel convinced that this 
organ should have been taken away when the abdo- 
men was opened, as it has left the patient only a 
companion to her appendix vermiformis-useless, 
and possibly dangerous. 
One question yet remains to be answered. Granted 
that patients are not having their lives risked to a 
greater degree than in oophorectomy, have those 
patients who have already undergone hysterectomy 
given evidence of the benefit we are striving to 
obtain ? 
A just conclusion is difficult to reach for two rea- 
sons : first, because of the varied methods of perform- 
ing the operation, and second, because of the char- 
acter of the previous disease. The old method of 
constricting the cervix-a barbarous and imperfect 
surgical procedure in the light of to-day-often sub- 
jected the tissues to a painful and perilous tension 
and invited hyperemia; adhesions to the anterior 9 
abdominal wall were common, and we all know the 
malevolent influence of adhesions; the amount of 
uterine tissue requisite for the application of the 
serre-noeud'N3& such that the endometrium was often 
encroached upon, and the stump that remained had 
poured into it the vast volume of the uterine artery- 
an inciter to riotous cell-action. 
The greater number of hysterectomies have been 
performed by this or some similar method down to a 
recent date, and I think that a judicious observer 
would hesitate to draw a conclusion as to the results 
of an ideal hysterectomy from patients who had been 
subjected to one of the old methods of operation. 
The character of the previous disease is so im- 
portant a factor that it would be gross negligence to 
ignore it. A hysterectomy for carcinoma might 
readily fail to bring about such a restoration to health 
as one would desire. It is almost impossible to be 
sure that the whole of the diseased tissue has been 
removed. To give a just verdict, the operation 
should be the one approaching the nearest to sur- 
gical perfection, and the cases should be of the 
character specified. Those that I have seen answer 
the question in the affirmative, Z. e., they have given 
evidence of such benefit. 
An old Irish woman who was cleaning the clinic- 
room, saw a jar containing a specimen, and asked 
what it was. On being told that it was a womb 
with tumors attached, taken from a patient who was 
now well and working hard, she replied : " Well, 
well, she won't live long. Nobody can without 
their womb. Everybody knows that. " 
This dictum from an ignorant person is a faint 10 
reflection of the attitude of the medical world in 
general. The uterus has long been labelled noli me 
tangere, for reasons too numerous to be recounted 
here, and I am an advocate of such a policy so far 
as indiscriminate operation is concerned, feeling 
that it is our duty to our patients to make every 
effort to bring about a normal condition without 
recourse to surgery; but when the latter is shown to 
be inevitable, it is equally our duty to do the work 
as thoroughly as possible. 
So far as I have been able to observe, removal of 
the uterus, when the ovaries and the tubes are doomed, 
does not lessen the feminine attributes of a woman. 
The knowledge that all diseased tissue has been re- 
moved and no useless organ allowed to remain is a 
comfort to the surgeon ; its absence does not appear 
to predispose to vaginal descensus or other lower 
pelvic disorder, and, by allowing the minimum of 
blood to the cervical stump, just sufficient to nourish 
it, reduces the chances of epithelioma-the dreaded 
bane of so many women-almost to the vanishing- 
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