Reflections on Hysterectomy
JOHN C. McDERMOTT, M.D.. Los Angeles
IN CONSIDERING the many changes in medical knowl-
edge and skills that have occurred since the time
of my medical school graduation just thirty years
ago, the thought came to mind that we frequently fail
to consider the bearing of all these changes on some
one particular problem. I would like to speak on
the subject of hysterectomy and the effect that these
changes should have on it.
Throughout the ages the uterus has been given a
very special status because of its function in the
beginning of all human life, and this led, at one time,
to attributing to it properties that we now know it
does not possess. I, among others, was told in medi-
cal school some thirty years ago that menstrual
blood would cause flowers to wither, the implication
(or at least the inference) being that menstruation
was a process of eliminating poisons from the body.
I must confess my failure as a true scientist in that
I did not test the validity of this statement. While
the medical profession no longer supports such a
view, reverberations from it still exist among women
who regard a profuse menstrual bleeding as a "good
period." While this misconception among the laity
can be eliminated by education, a similar one,
which still exists among some physicians, is that the
hormones produced by the ovaries require the
uterus for their proper metabolism. Another function
suggested many years ago was that the uterus pro-
duced a hormone itself. All experimental efforts to
support this suggestion have failed. Thus we come
to the one function that the uterus possesses and
about which there can be no argument-that of
childbearing. It is important to bear in mind that
this is its only known useful function.
The uterus has many undesirable attributes. Not
the least of these is normal menstruation. That in
the common parlance of women it is spoken of as
"the curse" is indicative of the average woman's
attitude toward it. Beyond mere inconvenience, ab-
normalities of bleeding are extremely common.
Menorrhagia frequently is sufficient to interfere with
usual activities. Dysmenorrhea is often incapacitat-
ing to a woman and a source of disturbance of
family life. Often a woman loses as much as one-
seventh of her life away from desired activities for
these two reasons. In addition, uterine tumors are
very common and they may be worrisome or costly.
Chairman's Address presented before the Section on Obstetrics and
Gynecology at the 90th Annual Session of the California Medical
Association, Los Angeles, April 30 to May 3. 1961.
96
* Except for childbearing, the uterus is not nec-
essary in the body economy. It is subject to many
troubles, many of which interfere with the pa-
tient's enjoyment of life, and some endanger
life seriously. In view of great improvement in
mortality and morbidity in the operation of hys-
terectomy, indications should be extended for
this operation, taking this lessened danger into
account.
And finally, uterine cancer; it is the second most
common cancer in women over the age of thirty.
Let us now trace the changing concepts and prac-
tices in operations involving the uterus as the author
knows them in the Los Angeles area. Thirty years
ago hysterectomy when done for nonmalignant dis-
ease was always subtotal. Some surgeons, giving
consideration to the ideas about the desirability of
menstruating, would even do fundectomy, deliber-
ately leaving some endometrial tissue. Preservation
of the uterus in cases of bilateral salpingectomy for
tubal disease gave -many a surgeon a satisfying
sense that he was conservative. Indeed an essay
written by me in 1938 advocating removal of the
uterus at such times was regarded as very radical.
Because of excessive hazards, total hysterectomy
was avoided except in cases of malignant disease.
The operative mortality on the gynecological wards
at the Los Angeles County General Hospital at that
time ran from 2 to 5 per cent-which made for
conservatism in advocating operation.
Progress since then has changed this whole pic-
ture. Improved knowledge of blood use, general
availability of blood, great strides in anesthesia and
the development of antibiotics have all been given
their share of credit. Less roundly recognized is the
better condition of the patient nowadays, due to
better diet, early feeding after operation, reduction
in the postoperative use of strong sedatives and
narcotics, and early ambulation. The most recent
development, and one that deserves much credit, is
the intensive care unit, in which the patient is spe-
cially and knowingly dealt with postoperatively
until physiological equilibrium has returned. All
these improvements have so reduced the risk that
death from hysterectomy is rare; and if death oc-
curs in association with hysterectomy, it usually is
not attributable to the operation.
All these changes, however, are in my opinion
but satellites of the most important one-the change
CALIFORNIA MEDICINE
from subtotal to total hysterectomy. The develop-
ment of satisfactory surgical technique that permits
removal of the whole uterus without increasing the
mortality or morbidity, that preserves the normal
anatomical features of the vagina and does not
leave a weakened area at the vaginal vault, means
that now hysterectomy succeeds in removing the
area of the uterus most susceptible to the develop-
ment of cancer and thus gives prophylactic value
to the operation.
About fifteen years ago a well known teacher of
gynecology presented an essay with the central
theme that a large number of hysterectomies per-
formed in his state were ill advised, if indeed they
were not in the nature of a racket. The attention
given to that essay, particularly in newspapers and
magazines, was so great that it inspired another
essay along the same lines a few years later by a
California author. And it, too, was quoted and con-
densed in lay magazines and achieved great pub-
licity as an effort to save the public from the "knife-
happy" medical profession. At the time, raising
a voice in protest against either of these essays
would have been construed as opposing virtue. The
primary premise promoted by these essays, and
indeed the one that has received the most support
in the past, is that the uterus must be given a very
special status among the organs that are not neces-
sary to the preservation of life. While removal of the
appendix when the abdomen is opened for other
VOL. 96, NO. 2 * FEBRUARY 1962
reasons is not only condoned but is urged as good
practice, and while a few attacks of tonsillitis are
taken as ample justification for tonsillectomy, hys-
terectomy is deplored unless there is no other
method of handling the problem at hand.- It is about
this special status of the uterus that we must have a
change of attitude in view of our changed knowl-
edge and skills.
Except for the childbearing function, the uterus
is a dispensable organ. Not only can a woman get
along satisfactorily without it, but without it she
is free of certain nuisances and dangers. This is
not by any means to say that hysterectomy is recom-
mended in all cases where childbearing is no longer
a consideration. What is recommended is that hys-
terectomy is a procedure of choice over myomec-
tomy, suspension and other less definitive pelvic
procedures when the childbearing function is no
longer a consideration. Furthermore a hysterectomy
should be done when menorrhagia or dysmenorrhea
is sufficient to interfere with the patient's enjoyment
of life and cannot be relieved by simpler measures.
It should be emphasized that hysterectomy is not
an operation to do indiscriminately, but it is my
hope that the indications for it will be adjusted to
take into account the improved operative results and
the prophylactic benefits to be obtained-and my
further hope that it will not be avoided for mystical
and unscientific reasons.
2010 Wilshire Boulevard, Los Angeles 57.
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