FIVE CASES 
OF 
Vaginal Hystorectomy 
FOR 
MALIGNANT DISEASE OF THE UTERUS 
ALL RECOVERED. 
BY 
W. F. McNUTT,M.D., L.R.C.P.,Ed., &c. 
Prof. Principles and Practice of Medicine, 
University of California. 
(reprinted from transactions of the medical society, state 
OF CALIFORNIA, 1890.) FIVE CASES OF VAGINAL HYSTORECTOMY 
FOR MALIGNANT DISEASE OF THE 
UTERUS. ALL RECOVERED. 
By W. F. McNUTT, M. D., M. R. C. S., Ed., etc. 
Prof. Principles and Practice of Medicine, University of California. 
Mrs. B., age fifty-seven, born New York, had one child, 1851, 
no cancer history, menstruated at seventeen, ceased at forty- 
one. At age fifty-three commenced having slight uterine hem- 
orrhages; consulted several physicians in regard to it, had taken 
medicine and had astringent injections, etc., with the effect of 
partially controlling the bleeding. When she consulted me 
first at my office she had slight hemorrhage, mixed with a thick 
ropy albuminous looking discharge—found the uterus slightly 
enlarged, canal tortuous and irregular, and had difficulty in 
passing the sound, neck granular and bleeding easily, made 
applications with astringents, ordered lead and carbolic injec- 
tions, advised rest. There being no improvement and consider- 
ing the case cancerous, I called Dr. R. Beverly Cole in consulta- 
tion; when we dilated the uterus, with Hager dilators, there was 
discharged at least a half an ounce of white-of-egg-like fluid 
mixed with blood, the whole neck of the uterus was nodular and 
presented an epithelial-like softened appearance. The woman 
was losing weight, strength and color, there was no mistaking 
the diagnosis, viz.: Epithelial cancer. 
Mrs. B. having consented to an operation, I determined to 
make a vaginal hystorectomy, and on November 27th, 1888, re- 
moved the uterus. The external parts were shaved and thor- 
oughly cleaned by soap and carbolized water, and the vagina 
was disinfected and the patient placed in the dorsal position. 
The uterus was brought down by a strong volsella and a small 
vertical incision was made through the anterior vaginal wall. 
An aneurism needle with a ligature was passed through the 
opening, and brought out through the wall three-fourths of an 
inch to the right; this section was tied and divided with scis- 
sors; this process was continued until the neck was enucleated, 
the connective cellular tissue was mostly broken up by the fin- 
ger; the uterus was then easily brought further down, not turned 
CASE NO. ONE. 2 
Vaginal Hysterectomy for Disease of the Uterus. 
over, and the broad ligaments secured in mass by a carbolized 
silk ligature. I then put on long compression forceps on the 
ligaments between the ligatures and uterus, and divided the 
broad ligaments close to the uterus up to its upper margin, and 
over this undivided upper fold of the ligament, I placed a liga- 
ture and cut the uterus free. I then tied these last two liga- 
tures together stretching the broad ligaments across the cavity 
and making a roof, as it were, to the vagina, the vagina was 
then packed with iodoform gauze, the forceps were taken off 
in forty-eight hours, and she was kept four weeks in bed, and 
now seventeen months after the operation is as well as she ever 
was. At no time after the operation was there any marked rise 
in temperature. 
I was assisted in this operation by Drs. Winslow .Anderson, 
J. C. Sundberg and Kate Howard. 
Of the pathology of this case Prof. D. W. Montgomery says, 
Mrs. B. had an extensive neoplasm of the cervix uteri, both 
simple and malignant. The simple new growth was a papilloma. 
Below the papilloma was a epithelioma infiltrating very exten- 
sively the connective tissue. 
CASK NO. TWO. 
Mrs. P., aged forty-four, married at twenty, two children, 
youngest seventeen years old, had one miscarriage thirteen 
years ago, no cancer history. This case was under the care of 
Dr. W. H. Davies, who had attended her for several months 
for uterine hemorrhage, using internal remedies, injections and 
several times having to tampon the vagina with cotton saturated 
with solution of monsel’s. 
Dr. Davies told her his efforts were only affording her tem- 
porary relief and more radical measures would have to be tried. 
I was called in consultation and found the patient exsanguine 
to an alarming degree, an epithelioma of the cervix was unmis- 
takable; the slightest touch caused profuse bleeding, necessitat- 
ing the tampon after our examination. We advised removal of 
the uterus, and after a few days’ delay she consented to the 
operation. July 25th, 1889, the operation was made, Dr. W. 
D. Garwood gave the patient ether, and, placing her in the 
lithotomy position, the epithelial fungous bleeding mass was 
curetted off and the bleeding in a measure controlled by hot 
water before the enucleation of the cervix was commenced. 
Drawing the uterus well down with a volsella, the enucleation 
was soon made, the adhesions separated, and the broad liga- Vaginal Hystorectomy for Disease of the Uterus. 
3 
ments clamped with compression forceps (no ligatures used), 
uterus cut loose, and forceps left on fifty hours. The only 
difficulty encountered in this operation was the exhausted and 
exsanguine condition of the patient before commencing the 
operation. During the later part of the operation she was con- 
stantly plied with hypodermic injections of whiskey, which were 
necessary to keep up the heart’s action. 
In this operation, I was assisted by Drs. Davies, J. C. Sund- 
berg, Winslow Anderson, Hodghead, W. H. Mays and Kate 
Howard. 
This patient is in excellent health and spirits at the present 
time, nine months after the operation, with the exception that 
she has a small vesico-vaginal fistula, and which did not give 
any evidence of its presence until after the fourth week. 
CASE NO. THREE HYSTORECTOMY (FOR CANCER) AND OVARIOTOMY 
DOUPLE OPERATION. 
Mrs. F., age sixty-seven, a thin, wiry, but apparently well 
nourished old lady came to Dr. R. M. Elliott, of this city, from 
Washington Territory on June 24th, 1889, suffering from an 
offensive discharge from the uterus. She had borne a large 
family of healthy children, and had never had any severe illness 
up to the present time. 
While riding on a buckboard about five months ago, the 
horses in leaping a ditch tipped her backwards, and she fell, 
striking on her sacrum. The injury caused her considerable 
pain at the time, but it gradually passed off leaving no notice- 
able trouble afterwards. A smooth, elastic, immovable, round 
tumor could be felt through the abdominal wall in the region 
of the left ovary. There was a purulent vaginitis, and an excori- 
ation of the os uteri with a purulent bad smelling discharge 
from the os. There had been at no time either pain or hemor- 
rhage. After cauterization by Dr. Elliott with nitrate of silver, 
the solid stick, the excoriation healed in part, the discharge 
from the os in a great measure ceased, and she returned to the 
country much improved, but with a slight discharge from the 
vagina which still persisted, and for which an injection of sul- 
phate of zinc and acetate of lead, each twenty grains; tincture of 
opium, one dram; and water to eight ounces was prescribed. 
After two weeks she wrote stating the offensive discharge had 
returned just as before. On coming back to the city again for 
treatment a much more serious state of affairs was found than at 4 
Vaginal Hyslorectomy for Disease of the Uterus. 
first. The discharge was as abundant as before instituting 
treatment, and a fungous easily bleeding mass was seen pro- 
jecting from the os uteri. 
Dr. Elliott called me in consultation and an operation was 
advised, the patient was sent to the Children’s Hospital and the 
date of operation set for August, 11th. 
Because of the abdominal tumor, the exact nature of which 
could not be determined before the operation, it was determined 
to first open the abdomen, examine its contents, and then act 
pro re nata. After a careful toilet, the abdomen was opened in 
the median line, and an ovarian cyst about the size of a cocoa- 
nut was found united by extensive adhesions to all the surround- 
ing viscera, especially to the intestines. The adhesions were 
carefully separated, principally by the finger nails. After much 
labor the tumor was set free from the intestines, it still being 
firmly adherent to the uterus. The cyst contents were then 
evacuated. The uterus was found much enlarged, being about 
the size it should be at the second month of gestation; it was 
soft and boggy to the touch; and adherent to the surrounding 
tissues, especially posteriorly, an abscess being found between 
the uterus and the rectum. I then decided to enucleate the neck 
of the uterus per vagina and remove the uterus through the ab- 
dominal opening. In enucleating the neck and going up 
between the rectum and the uterus the aforementioned abscess 
was opened and a large quan tity of foul smelling pus was evac- 
uated. The os uteri was also opened up and a large quantity 
of pus followed away from the uterine cavity. The pus being 
got rid of per vaginum, and the neck being thoroughly enucle- 
ated, the operative procedures were subsequently carried on 
through the abdominal opening, removing the entire womb, the 
cyst in connection with it, and the left Fallopian tube. 
Despite the age of the patient, the length of the operation 
(lasting fully three hours), and the amount of disturbance 
caused by the breaking up of the very extensive adhesions and 
the separation of such large masses of tissue, the patient’s tem- 
perature never went above 101°, and the only bad symptom was 
some meteorism occurring on the third day and gradually sub- 
siding again. Very little blood was lost during the operation, a 
point of great importance in elderly persons in whom the blood- 
making functions are not active. 
Mrs. F. sat up on the 14th day and left the hospital on the 
28th. Vaginal Hystorectomy for Disease of the Uterus. 
5 
I wish to acknowledge the assistance of Drs. Winslow Ander- 
son, Brown, Elliott, Mays, Montgomery and Wanzer. 
Dr. D. W. Montgomery’s report on the pathology of the 
parts removed appeared in the reports of San Francisco Medi- 
cal Society where the specimens were shown. He says that it 
was an epithelioma of the cervix uteri, the infiltration involved 
pretty much the whole cervix. 
CASE NO. FOUB. 
Mrs. P., age thirty-two, married, had children—was under Dr. 
S. S. Stambaugh’s care for several months for fever, pain and 
uterine hemorrhage. I examined her in consultation with Dr. 
Stambaugh August 27, 1889; the uterus was much enlarged and 
immovable, cervix nodulated and vascular with granulating 
bleeding surface, broad ligaments thickened. There was a bad 
smelling vaginal discharge. There was no doubt about the 
cancerous nature of the disease. Mrs. P. came from a very 
malarious locality, and had high fever every day, notwithstand- 
ing Dr. Stambaugh had treated her for malaria. 
We informed Mrs. P. of the nature of her disease, and that 
nothing but an operation offered her any chance from a disease 
which must soon prove fatal. The enlargement and fixed con- 
dition of the uterus with the involvement of the broad ligaments 
made the prospect for an operation bad. She, however, wanted 
to avail herself of the chance an operation would afford, and on 
September 12, 1889, I operated with the assistance of Drs. 
Stambaugh, .Winslow Anderson, Paugh and Stone. After the 
usual careful preparation as to washing, shaving and vaginal 
antiseptics, the uterus was seized with strong volsella, but on 
account of the fixed condition could be pulled down but little, 
the neck was soon enucleated with the instruments which you 
see here, and which I had made for the purpose. 
The extensive adhesions were broken up with great difficulty, 
and the ligaments were so involved that it was necessary to re- 
move them as you see. 
The hemorrhage was controlled by compression forceps, which 
remained on about fifty-two hours, no ligatures used, the vagina 
filled, as all the other cases were, with iodoform gauze and the 
woman put to bed. She at no time had so much fever after 
the operation as she had before, she made a good recovery. 
Mrs. W., age 38, born in France, first menstruated at the age 
of 15, never was regular, married at 23, one miscarriage five 
CASE NO. FIVE. 6 
Vaginal Hysterectomy for Disease of the Uterus. 
years after, caused by lifting a heavy weight, followed by 
metritis and peritonitis, was confined to bed two months, never 
fully recovered; no cancer history. 
Began to complain of uterine pain and hemorrhage about three 
months ago, and for which she had consulted physicians at 
various times, who had given her medicine and injections with- 
out relief. She consulted Dr. Frances R. Marx, who, consider- 
ing the case cancerous, called me in consultation. On examina- 
tion I found great tenderness, the whole uterus enlarged and 
fixed, cervix indurated and nodular with very vascular granula- 
tion, which bled freely from the slightest touch; there was a 
constant watery, bloody colored discharge, having a character- 
istic odor; the cancerous cachexia was well marked and the 
diagnosis of cancer was unmistakable. 
Being informed of the nature of her case and the only remedy, 
removal of the uterus, she at once consented to an operation. 
She was sent to the Children’s Hospital. December 3, 1889, I 
removed the uterus. On account of the large size and fixed 
condition of the uterus, accompanied with the fact that the 
woman had never borne children, made the operation a most 
difficult one. After enucleating the cervix and separating the 
adhesions to the bladder it was still impossible to pull the 
uterus down—the attempt to turn it over backward was equally 
unsuccessful. After a time, however, I succeeded in turning it 
over forward, having fixed one blade of the volsella into the 
fundus and made steady traction. The broad ligaments were 
then clamped with compression forceps (no ligatures used), and 
the operation finished by cutting the broad ligaments. The 
vagina was packed with iodoform gauze and the forceps removed 
after forty-eight hours. This large fibrous tumor which you 
see in the fundus of the uterus is what prevented the uterus 
from descending and made it so impossible to turn it over 
backwards. 
The operation altogether was very difficult, and the hemor- 
rhage from this softened, vascular, broken down cervical por- 
tion was excessive and uncontrolable during the operation. The 
woman, though exsanguine by the time the operation was 
finished, made a good recovery, and is at the present time en- 
joying very fair health. 
I was assisted by Drs. D. W. Montgomery, C. B. Brown, F. 
R. Marx, Winslow Anderson, A. A. D’Ancona and Wanzer. 
The first operation was the only one in which I used the aneur- Vaginal Hystorectomy for Disease of the Uterus. 
7 
ismal needle and ligature in enucleating the cervix, in all the 
other cases the enucleation was made by these instruments, 
which I show you here and which I had made for the purpose. 
It is not my purpose to discuss the etiology of cancer of the 
uterus with a view of determining its relation to laceration of 
the cervix, pregnancy, etc., nor to enter into any detailed ac- 
count of the pathology or symptomatology of uterine cancer. 
But my object in reporting these cases is to call the attention of 
the members of this Society to the fact that we have in hystor- 
ectomy a remedy even for cancer of the uterus, and to assist in 
establishing hystorectomy as a legitimate and recognized sur- 
gical operation, and to hasten the time when the surgeon will as 
promptly and confidently resort to removal of the uterus for 
cancer as he does to the removal of the breast. 
Of these five cases all were married women, four had borne 
children, while the fifth case had had one miscarriage. 
About the frequency of cancer of the body of the uterus as 
compared with that of the cervix there is great diversity of 
opinion, as is also the case in regard to the merits of the opera- 
tive procedures for cancer of the cervix, viz.: "Whether to re- 
move the cervix only or make hystorectomy. A recent able 
writer on cancer of the uterus, viz: Dr. John Williams, Professor 
of Obstetrics, in Queen’s College, London, strongly advocates 
amputation of the cervix when the cancer apparently involves 
only the cervix, saying: “That it is possible to extirpate cancer 
from the uterus by supra-vaginal amputation, and that, in so far 
as the prevention of recurrence in the uterus itself is concerned, 
total extirpation of the organ presents no advantages over 
partial amputation.” 
It is not so surprising that Dr. Williams takes this ground, 
as he believes he has fully demonstrated that the tendency of 
cancer of the cervix is to spread laterally rather than to follow 
up the uterine cavity and involve the body of the womb. A 
careful examination by Prof. Montgomery of these uteri which 
you see here does not go to confirm Dr. Williams’ opinion, that 
in cancer of the cervix the tendency is only to extend laterally. 
Dr. Montgomery found the cancer cell extending up the mucous 
lining of the uterine canal. While Dr. Williams advocates and 
practices the supra-vaginal amputation, he certainly has failed 
to make it clear how we are to diagnose with any certainty in 
which cases there is no cancerous involvement extending above 
the cervix. 8 
Vaginal Hystorectomy for Disease of the Uterus. 
There may be cases when this supra-vaginal amputation would 
be all that is necessary; in many cases, however, the cancerous 
tissue would not all be removed, and there is no means of differ- 
entiating the cases. 
In connection with these cases I will crave the indulgence of 
the Society to say a word about laparotomy. Now that laparo- 
tomy has become so common, no one thinks of making an 
elaborate and detailed account of this operation. In the 
past year I have, however, made three or four that are not devoid 
of interest to those who are interested in abdominal surgery. 
Two of the cases proved to be intraligamentous cysts, one very 
large, no pedicle, embedded between the layers of the broad 
ligament deep into the pelvis. Enucleation was first attempted, 
but the capsule was so vascular that the attempt to shell it out 
had to be abandoned. I finally tied its whole broad base in 
eight sections; including too much tissue in the last section next 
to the uterus, the ligature cut the tissues and the bleeding was 
profuse. After cutting away the sac close to the ligatures, I 
resorted to powdered monsel’s to stop the hemorrhage, which it 
did, using about three teaspooufuls. A drainage tube was used 
and the wound closed in the usual manner. There was consid- 
erable inflammation with temperature of 104 for three or four 
days, when the fever subsided and the patient made a good 
recovery, and was out in five weeks. In the second intralig- 
amentous case the cyst was small, and there was no difficulty 
in enucleating it. The hemorrhage, however, was very profuse, 
and was again checked by putting monsel’s freely into the bed of 
the cyst. A drainage tube was used. Some fever followed, and 
the woman made a good recovery. 
These two cases make up my experience with monsel’s in the 
abdominal cavity. Just how to manage these intraligamentous 
cysts seems to be a matter for each individual operator to de- 
termine after he has opened the abdomen and carefully examined 
the case at hand. The third interesting case was that of a solid 
ovarian tumor weighing between seven and eight pounds. The 
woman, though very weak, made a good recovery. 
Prof. Montgomery, after a careful examination, determined it 
to be a fibroid. While solid ovarian tumors are not common, the 
fibroid variety is probably the least common of all. The most 
troublesome part of the operation for these solid tumors often 
is the management of the intestines, owing to the great length 
of the opening required to lift out the tumor.