Vaginal Hysterectomy in 
America, with Report 
of Two Cases. 
BY 
A. PALMER DUDLEY, M. D., 
burgeon, st. Elizabeth's hospital. 
REPRINTED FROM 
2Tt)e Neto York fCUDical .JJoucnal 
for July 9 and 16, 188H. Reprinted from the New York Medical Journal for July 9 and 16, 1887. 
VAGINAL HYSTERECTOMY IN AMERICA, 
WITH REPORT OF TWO CASES. 
By A. PALMER DUDLEY, M. D., 
SURGEON, ST. ELIZABETH'S HOSPITAL. 
In no branch of the surgical art has greater advancement been made 
during the past twenty years than in the field of gynaecology. 
America justly lays claim to her share in this progress. During the 
time mentioned, hystero-trachelorrhaphy has traversed the rugged path to 
success, and laparotomy, for various forms of disease, has struggled from 
infancy with its many enemies to maturity with its thousands of friends, 
and now occupies an enduring place in modern and future surgery. 
In the same manner vaginal hysterectomy sprang into existence as a 
surgical procedure for the relief of a disease most loathsome and dreaded. 
It is a procedure yet in its infancy, but is daily laying increasing claims 
upon the profession for recognition, and, although not having its origin in 
America (for Andreas, of Cruce, is supposed to have done it in 1560, and 
Langenbeck is known to have done it in 1813, followed by Santu in 1822, 
Blundell in 1828, and Recamier in 1829), it was not looked upon with 
favor, and remained dormant as a surgical wonder until April 12, 1878, 
when Czerny revived it and did the operation which, with few changes, is 
the accepted operation of to-day. In Europe, during the past ten years, 
much has been written upon this subject, with scarcely a passing reference 
to American work. Here even the operation has been looked upon as an 
unsurgical procedure, cried down by almost the entire profession, while in 
the small amount of space devoted to it in our medical literature, foreign 
quotations and praise make up the major portions of the articles, much to 
the discredit of our own profession. My object in this paper will be to 
show what the profession of this country has accomplished with this 
operation, to place upon record a series of cases with individual methods 
of operation and treatment, and statistics which can not fail to be of in- 
terest, and to give America a just title to original work in this, as well as 
the operations previously mentioned. 
* Read before the Alumni Association of the Woman's Hospital at its third meeting. 2 
VAGINAL HYSTERECTOMY IN AMERICA. 
No. 
Name of sur- 
geon. 
b£) 
Description of 
case. 
Manner of operation. 
Date of op- 
eration. 
Result. 
When last seen. 
Remarks. 
I. 
Dr. Anderson, 
San Fran- 
cisco. 
56 
Carcinoma of cer- 
vix and body. 
Circular incision of vagi- 
nal vault with a gal- 
vano-cautery. 
October 26, 
1881. 
Recovery, 
with a vesi- 
cal fistula. 
February, 1882; no return 
of the disease. 
I. 
Dr. W. H. Ba- 
ker, Boston. 
Not pub- 
lished. 
54 
Carcinoma of body 
of uterus. 
Anterior, then posterior, 
incision; uterus retro- 
verted; section lig'tures; 
wound dressed openly. 
March 24, 
1885. 
Recovery. 
Disease returned in Octo- 
ber, 1885 ; died May 25, 
1886. 
I. 
Dr. A. C. Ber- 
nays, St. 
Louis. 
52 
Epithelioma, in- 
volving both lips 
of the portio va- 
ginalis. 
Dec. 12, 
1883. 
Recovery. 
November 24, 1886; in 
good health. 
Had peritonitis lasting 
only a short time. 
II. 
cc 
41 
Epithelioma of cer- 
vix and extend- 
ing into the body 
• • 
May 10, 
1884. 
Recovery 
rapid. 
December, 1886; no re- 
turn. 
Uninterrupted recovery. 
III. 
IV. 
u 
42 
50 
Epithelioma of 
cervix and body; 
organ much en- 
larged. 
Epithelioma of cer- 
vix, involving 
some of vaginal 
vault. 
March 26, 
1885. 
June 5, 
1885. 
Recovery 
rapid. 
Recovery 
rapid. 
November 1, 1886; no re- 
turn of the disease. 
July 4, 1886; examined 
and found no return of 
the disease. 
Had some peritonitis 
with suppuration; 
tubes and ovaries re- 
moved with the uterus 
V. 
36 
Epithelioma; the 
entire posterior 
lip of c'rvix gone; 
growth extended 
into the body. 
August 1, 
1885. 
Recovery 
rapid. 
December 3, 1886 ; slight 
suspicious thickening in 
the cicatrix. 
Had secondary haemor- 
rhage requiring liga- 
tion of small artery 
on the fifth day. 
VI. 
a 
34 
Epithelioma of cer- 
vix, extending to 
the internal os. 
November 
4, 1885. 
Recovery 
rapid. 
December 4, 1886 ; no re- 
turn. 
I. 
Dr. J.G.Blake, 
B'st'n. "Bos- 
ton Med. & 
Surg. Jour." 
42 
Carcinoma of the 
cervix. 
Circular incision; liga- 
ments ligated en masse; 
uterus removed without 
version. 
January 28, 
1880. 
Death in 12 
hours from 
shock. 
The parts were so vas- 
cular the loss of blood 
was great. VAGINAL HYSTERECTOMY IX AMERICA. 
3 
I. 
Dr. Wm. T. 
451 Epithelioma of the 
Circular incision; uterus 
February 
Recovery 
In October, 1883, the dis- 
Vagina tamponed with 
Bull, New 
York, "New 
York Med. 
Journal." 
cervix uteri. 
anteverted; broad liga- 
ments tied in sections; 
open dressing. 
19, 1883. 
rapid. 
ease reappeared, and 
she died in eighteen 
months. 
peat-bags. 
II. 
a 
86 
Epithelial growth 
upon the cervix; 
cauliflower. 
u 
August 16, 
1884. 
Recovery. 
March, 1886. Death from 
carcinoma of the peri- 
tonaeum. 
Five days before the 
hysterectomy the 
cauliflower cervix was 
removed. 
III. 
ci 
85 
Epithelioma of the 
cervix, extending 
to internal os. 
Circular incision; uterus 
retroverted; broad liga- 
ments tied in sections. 
September 
24, 1884. 
Recovery. 
September, 1886, she re- 
mained well. 
One suture placed across 
the vaginal wound. 
IV. 
u 
52 
Epithelioma of the 
cervix. 
Posterior and lateral in- 
cision ; uterus retro- 
verted ; open dressing. 
July 4, 
1886. 
Recovery. 
Right broad ligament 
tied in sections ; left 
broad ligament cut 
with cautery. 
V.' 
a 
43 
Cauliflower of the 
cervix. 
Uterus pulled down with 
silver wire and cut away 
from rect'm and bladd'r. 
August 27, 
1886. 
Death Au- 
gust 27, 
1886. 
Two transfusions of saline 
fluid before death. 
I Hemorrhage in meso- 
rectum. 
I. 
Dr. • Burke, 
Connectic't. 
Not report- 
ed. 
37 
Sarcoma of cervix; 
cauliflower. 
Uterine arteries ligated; 
uterus drawn down; cul- 
de-sac opened; liga- 
ments tied en masse ; 
uterus severed & drawn 
down; vagina stretched. 
November 
11, 1882. 
Recovery 
rapid. 
During the present month, 
and found in good con- 
dition. 
The cervix was amputa- 
ted six months pre- 
vious to the operation 
for hysterectomy. 
I. 
Dr. Cushing, 
San Francis- 
co. " Am. 
Jour, of the 
Med. Sci.," 
1882. 
47 
Carcinoma of the 
cervix uteri. 
Sims's position; uterine ar- 
teries ligated; uterus 
separated from bladder; 
ovarian arteries tied; 
uterus retroverted; vag- 
inal wound left open. 
September 
4, 1881. 
Recovery 
rapid. 
One year after operation. 
Disease returned in six 
months and caused 
death in one year. 
I. 
Dr. B. F. Daw- 
son, New 
York. "Am. 
Journal of 
Obstetrics." 
Diffuse sarcoma of 
themucousmem- 
brane of the 
uterus. 
Circular incision; uterus 
drawn down and not 
ante- or retroverted, ow- 
ing to presence of a fi- 
broid in the body. 
April 7, 
1885. 
Death on 
3d day 
from fever. 
The uterus contained two 
fibroids, one interstitial. 
Autopsy showed fatty 
degeneration of the 
kidneys. VAGINAL HYSTERECTOMY IN AMERICA. 
4 
No. 
Name of sur- 
geon. 
o5 
Description of 
case. 
Manner of operation. 
Date of op- 
eration. 
Result. 
When last seen. 
Remarks. 
I. 
Dr. De Vecchi, 
San Francis- 
co. "West- 
ern Lancet" 
1883. 
53 
Epithelioma of the 
cervix and va- 
gina. 
Incision by galvano-cau- 
tery wire; mass liga- 
tures ; uterus retro- 
verted. 
March 1, 
1883. 
Rapid rec'v- 
ery; died 2 
years and 3 
months 
after. 
She was under observation 
till death; the disease 
showed evidence of re- 
turn in one year. 
The disease involved ab- 
dominal organs; pa- 
tient died in great 
agony. 
II. 
G 
50 
g 
G 
No date. 
Rapid re- 
covery. 
The disease returned in 
6 months, and the pa- 
tient died before the 
6th mo. had passed. 
I. 
Dr. A. Palmer 
Dudley, N'w 
York. 
4 1 
Epithelioma of the 
cervix and right 
vaginal wall. 
Anterior vaginal opening; 
uterus anteverted; liga- 
ments tied in sections; 
open dressing. 
December 
20, 1883. 
Recovery 
rapid. 
One year after operation; 
no return of the dis- 
ease. 
Death from laparotomy 
for entero-vaginal fis- 
tula. 
II. 
I. 
Dr. A. Palmer 
Dudley, N'w 
York. 
Dr. E. C. Dud- 
ley, Chica- 
go. Not re- 
ported. 
48 
Epithelioma of the 
cervix and body. 
Carcinoma of the 
cervix and ex- 
tending into the 
body of uterus. 
Anterior vaginal opening; 
uterus anteverted; liga- 
ments tied in sections; 
open dressing. 
Czerny's method of opera- 
tion. 
December 
28, 1886. 
May 23, 
1882. 
Death in 39 
hours from 
acute ne- 
phritis. 
Died in four 
hours from 
shock. 
Complete suppression of 
urine twelve hours 
before death. 
I. 
Dr. J. W. El- 
liot, Bos- 
ton. "Bost'n 
Med. & Sur. 
Jour.," July 
22, 1885. 
39 
Epithelioma of the 
cervix uteri. 
High amputation; ante- 
rior cul-de-sac opened; 
uterus anteverted; vag- 
inal wound tamponed 
with iodoform gauze. 
May 12, 
1885. 
Death on 
the Sth day 
from haem- 
orrhage. 
This patient had high 
amputation in Janua- 
ry, 1885; was again 
curetted in March; 
death caused by haem- 
orrhage from torn 
adhesions. 
I. 
Dr. P. F. Eve. 
" Am. Jour, 
of the Med. 
Sci.," 1850. 
28 
Encephaloid of ap- 
parently entire 
uterus and upper 
part of vagina. 
Forcibly drawn down and 
removed with a knife. 
April 16, 
1850. 
Recovery 
rapid. 
Two months after opera- 
tion; growth found re- 
turning in the scar. 
Death July 22, 1850, 
three months and one 
week after the opera- 
tion. VAGINAL HYSTERECTOMY IN AMERICA. 
5 
I. 
Dr. C. Fenger, 
40 
Carcinoma of cer- 
Uterus anteverted; broad 
September 
Recovery inlThe disease returned 
in 
A fistula made in the 
Chicago. 
vix and lower 
ligaments tied in two 
19, 1881. 
four weeks. 
the posterior wall 
of 
bladder at time of 
"Trans, of 
half of the body 
sections; vaginal wound 
Died in 
bladder in 1884. 
operation was closed 
the Am. 
of uterus. 
closed with silk. 
Mav, 1885. 
with silk; the latter 
Gynaec. So- 
ciety." 
was a nidus for stone 
passed six months 
later. 
I. 
Dr. M. Frank- 
lin, Phila- 
40 
Epithelioma of the 
cervix uteri. 
November 
Death on 
Autopsy gave no evi- 
11, 1882. 
fifth day 
dence of peritonitis; 
delphia. 
from shock. 
only a few lymph b'nds 
about the intestines, 
at the seat of the 
operation. 
I. 
Dr. Goodell, 
50 
Epithelioma of the 
Anterior, then posterior 
November 
Died No- 
Death caused by septicae- 
Iodoform tampon used, 
Philadel- 
cervix uteri. 
incision; uterus retro- 
13, 1883. 
vember 15, 
mi a. 
and vaginal wound 
phia. 
verted; ligaments tied 
in sections. 
1883. 
left open. 
II. 
Cl 
64 
u 
l< 
March 3, 
Recovery. 
Died October 25, 1886, 
1886. 
from vaginal haemor- 
rhage. 
Cervix amputated six 
I. 
Dr. R. J. Hall, 
35 
Epithelioma of the 
Operation made for haem- 
August, 
Recovery. 
Seen last November; 
she 
New York. 
Not report- 
ed. 
50 
cervix and ex- 
tending into the 
body of uterus. 
orrhage; Douglas's cul- 
de-sac opened; uterus 
retroverted; open dress- 
ing; ligaments tied in 
three sections. 
Lithotomy position; ante- 
1886. 
October 24, 
Death same 
was then well. 
weeks before the op- 
eration ; the intes- 
tines prolapsed dur- 
ing the operation. 
This operation was very 
difficult, owing to pa- 
I. 
Dr. J. B. Hun- 
Carcinoma of cer- 
ter, New 
vix and body. 
rior incision, then poste- 
1885. 
evening 
York. Not 
rior, and uterus ante- 
from shock. 
tient's fleshiness and 
published. 
verted; section ligature 
of ligaments. 
Curetted and stitched 
narrow vagina. 
I. 
Dr. E. J. Ill, 
42 
Cauliflower of cer- 
May 30, 
Recovery. 
April 11, 1886; she shows 
November 17, 1886, still 
in good general 
New Jersey. 
vix. 
wound up ; incision on 
1885. 
evidence of return 
of 
"N.Y. Med. 
right side first; anterior 
the disease. 
health. 
Jour.," Feb. 
cul-de-sac opened and 
13, 1886. 
uterus anteverted; then 
left side treated, 6 
VAGINAL HYSTERECTOMY IN AMERICA. 
No. 
Name of sur- 
geon. 
bD 
Description of 
case. 
Manner of operation. 
Date of op- 
eration. 
Result. 
When last seen. 
Remarks. 
I. 
I. 
I. 
II. 
III. 
IV. 
V. 
VI. 
VII. 
Dr. J. Taber 
Johnson, 
Washingt'n 
< 
Dr.Fr'dLange, 
New York. 
" Report of 
Surgical So- 
ciety." 
Dr. L. C. Lane, 
San Fran- 
cisco. 
a 
u 
u 
ll 
Dr. L. C. Lane, 
San Fran- 
cisco. 
14 
27 
60 
r. 
Epithelioma of the 
cervix extending 
into the internal 
os. 
Carcinoma of the 
cervix extending 
into the body. 
Epithelioma of the 
cervix uteri. 
cc 
ll 
ll 
ll 
Epithelioma of the 
cervix uteri. 
cc 
Anterior, then posterior, 
cul-de-sac opened; uter- 
us retroverted; section 
ligatures; iodoform 
dressing. 
Martin's method; uterus 
retroverted; ligaments 
tied in sections. 
June, 1885. 
November 
11, 1886. 
November 
'11, 1878. 
1878. 
1884. 
1885. 
1885. 
1886. 
1886. 
Death in 4 
days from 
peritonitis. 
Recovery 
rapid. 
Recovery 
rapid. 
Recovery 
rapid. 
Recovery 
rapid. 
Died in 48 
hours from 
septicaemia. 
Died 1 week 
later from 
peritonitis. 
Recovery. 
Died two 
days after- 
ward. 
Four months before the 
operation the diseas'd 
cervix was curetted 
and cauterized. 
Autopsy showed no re- 
turn of the disease in 
the pelvis, but the 
mesenteric glands 
contained cancerous 
deposits. 
Death from pelvic ab- 
scess, which burst in- 
ternally. 
There was a speedy re- 
turn of the disease. 
The autopsy revealed 
retro-peritoneal haem- 
orrhage of some 
standing. 
February 5, 1887; per- 
fectly well. 
One year after, when she 
had ascites, and died 
soon afterward. 
Two months after opera- 
tion. 
Still living and doing well. 
Four months after opera- 
tion. VAGINAL HYSTERECTOMY IN AMERICA. 
7 
VIII. 
c< 
« 
1886. 
Rapid re- 
covery. 
January 1, 1887. 
Well at the present 
time. 
IX. 
44 
December 
Rapid re- 
covery. 
Well at the present 
time. 
4, 1886. 
I. 
Dr.W. II. May, 
Stockton, 
Carcinoma of the 
Circular incision; Doug- 
las's cu'-de-sac opened 
September, 
1882. 
Death on 
Cause of death un- 
cervix uteri. 
the fifth 
known. 
Cal. 
first; uterus retrovert- 
ed; ligaments tied in 
three sections. 
day. 
I. 
Dr. Paul F. 
43 
Epithelioma of the 
Sims's position; anterior, 
October 10, 
Recovery. 
The disease returned in 
The ovaries and tubes 
Munde, N'w 
cervix uteri. 
then posterior incision 
1883. 
nine months. 
were removed with 
York. "Tr. 
of vagina; uterus retro- 
the uterus. 
Am. Gynrec. 
verted; then ligaments 
Soc.," 1884. 
tied in three sections. 
II. 
44 
30 
Sarcoma of the cer- 
44 
November 
Death in 40 
vix uteri. 
9, 1883. 
hours from 
internal 
bleeding. 
III. 
Dr. Paul F. 
17 
Epithelioma of the 
cervix ingrafted 
Lithotomy position; open'd 
first cul-de-sac; retro- 
January 30, 
1885. 
Death in 30 
Although this operation 
was more difficult 
Munde, N'w 
hours from 
York. "N'w 
upon lips of an 
verted uterus; ligaments 
shock. 
than the previous, he 
prefers the lithotomy 
York Obst. 
old lacerated 
tied in three sections. 
Soc.," 1884. 
cervix. 
position. 
I. 
Dr. Polk, New 
27 
Epithelioma of the 
Patient upon the back; 
July 14, 
Death on 
On the sixth day. 
Cause of death, septic 
York. 
cervix and body. 
circular incision of vag- 
1884. 
the sixth 
peritonitis. 
inal vault; uterus retro- 
verted. 
day. 
II. 
u 
31 
Epithelioma of the 
Operation similar, but the 
January 6, 
Recovery 
Three months after opera- 
The disease returned in 
cervix and body, 
uterus anteverted and 
1886. 
rapid. 
tion. 
three months. 
the uterus mov- 
able. 
removed. 
III. 
44 
57 
44 
Operation similar, but the 
uterus retroverted. 
March, 
Recovery 
rapid. 
Patient now well. 
1886.' 
IV. 
u 
66 
44 
Operation similar, but the 
May 27, 
44 
Seen last September, 1886, 
This was a very fleshy 
uterus anteverted. 
1886. 
and disease found re- 
patient, with a nar- 
turning. 
row pelvis, 8 
VAGINAL HYSTERECTOMY IN AMERICA. 
No. 
Name of sur- 
geon. 
St 
Description of 
case. 
Manner of operation. 
Date of op- 
eration. 
Result. 
When last seen. 
Remarks. 
V. 
u 
55 
Epithelioma of cer- 
vix and body, 
and the vaginal 
wall posteriorly. 
As in previous cases, but 
he was obliged to ante- 
vert the uterus. 
November, 
1886. 
Death in 
14 hours 
from shock. 
The autopsy showed im- 
plication of the glands 
of the broad liga- 
ments, evidence that 
the disease was not all 
removed at the time 
of the operation. 
VI. 
ii 
45 
Epithelioma of the 
cervix extending 
to the internal 
os. 
On the back ; anterior and 
posterior incisions with 
cautery; high amputa- 
tion of the cervix, then 
the body anteverted. 
December 
18, 1886. 
Recovery 
rapid. 
Patient doing well at 
present. 
I. 
Dr. Reamy, 
Cincinnati. 
Epithelioma of the 
cervix and one 
half of the body 
of uterus. 
Uterus anteverted; after 
ligating uterine arteries 
and broad ligaments, 
stitched the peritonaeum 
to vaginal wall. 
August, 
1886. 
Death in 
48 hours 
from shock. 
Long ligatures were 
left, and vaginal 
wound left open. 
II. 
(4 
47 
Sarcoma of the 
body of the uter- 
us, not involving 
the cervix. 
cc 
November 
8, 1886. 
Recovery in 
4 weeks. 
The temperature never 
rose above 101°, or 
pulse above 108. 
I. 
Dr. W. E. Tay- 
lor, San 
Francisco. 
Not report- 
ed. 
IS 
Carcinoma of the 
cervix. 
Circular incision; posterior 
cul-de-sac opened; uter- 
us retroverted; section 
ligatures; vaginal wound 
sutured. 
August 14, 
1881. 
Recovery 
rapid. 
The disease returned in 
April, 1882 ; death took 
place in August, 1882. 
II. 
u 
51 
Carcinoma of cer- 
vix and vaginal 
wall. 
Il 
August 19, 
1881. 
Death Au- 
gust 20, 
1881. 
In both these cases there 
was prolapse of the 
intestines into the 
vagina during the 
operation. 
I. 
Dr. Thomas, 
New York. 
Not pub- 
lished. 
69 
Epithelioma of the 
cervix extending 
into the body. 
Uterus retroverted thro'gh 
Douglas's cul-de-sac. 
October 5, 
1882. 
Died on 7th 
day from 
septicaemia. 
The patient was much 
exhausted prior to 
the operation. VAGINAL HYSTERECTOMY IN AMERICA. 
9 
I. 
Dr. Van Ram- 
30 
Epithelioma of cer- 
Sims's position; amputa- 
July 16, 
Recovery. 
December 26, 1886 ; vagi-!Ovaries and tubes were 
I. 
dohr, New 
York. 
Dr. Von Hoff- 
37 
vix extending to 
internal os. 
Carcinoma of the 
tion of posterior lip of 
cervix; ligature of uter- 
ine arteries; uterus an- 
teverted; iod. tampon. 
Bladder separated from 
1886. 
October 25, 
Recovery 
nal roof feels hard and 
suspicious. 
not removed. 
Post mortem showed 
IL 
man, San 
Francisco. 
Not pub- 
lished. 
44 
86 
cervix existing 
four months. 
Carcinoma of body 
vagina first; then Doug- 
las's cul-de-sac opened, 
and uterus retroverted. 
44 
1883. 
May 1, 
rapid; died 
January 14, 
1884. 
Recovery. 
Well at the present time. 
carcinoma of omen- 
tum and peritonaeum, 
but no return in the 
pelvis. 
III. 
44 
50 
of uterus, exist- 
ing six months. 
Carcinoma of cer- 
Uterus retroverted; vagi- 
nal wound left open. 
44 
1886. 
Fall of 
Recovery. 
History of this and the 
IV. 
44 
53 
vix. 
44 
44 
1884. 
Fall of 
Recovery. 
following patient lost; 
they came from a dis- 
tance, went home well 
in four weeks, and 
have not been heard 
I. 
Dr. R. F.Weir, 
New York. 
" Trans. N. 
Y. Surgical 
Society." 
44 
40 
Epithelioma of the 
Lithotomy position; blad- 
1884. 
November 
Recovery. 
April 27, '85 ; the growth 
had commenced to re- 
turn. 
Patient only lived a few 
from since. 
II. 
15 
cervix uteri; cau- 
liflower. 
Epithelioma of cer- 
der separated first; uter- 
us anteverted; broad 
ligaments tied in three 
sections; vagina closed 
with catgut. 
44 
10, 1884. 
May 16, 
Death from 
Uterus much enlarged, 
I. 
Not pub- 
lished. 
Dr. Wile,Conn. 
49 
vix uteri. 
Carcinoma of the 
Bladder perforated by a 
retractor. 
Anterior incision; silk 
ligature carried over 
right broad ligament; 
then posterior vaginal 
wall opened, and left 
side treated. 
Divided uterus longitudin- 
1885. 
November 
shock and 
loss of 
blood. 
Died No- 
hours. 
She had a sharp haemor- 
complicating the op- 
eration. 
During the operation 
I. 
"New Eng- 
land Med. 
Monthly," 
Feb. 15, 
1883. 
Dr. C. M. Wil- 
50 
cervix uteri. 
Carcinoma of an 
13, 1882. 
September, 
vember 16, 
from 
shock. 
Recovery. 
rhage from the right 
uterine artery, and it 
was ligated the second 
time. 
December 14, 1886; still 
in good health, with no 
evidence of return. 
the intestines pro- 
lapsed into the va- 
gina. 
The inversion had ex- 
son, Phila- 
d'lphia. Not 
published. 
inverted uterus. 
ally; tied arteries with 
catgut, and touched 
stump with cautery. 
1886. 
isted for six years. 10 
VAGINAL HYSTERECTOMY IN AMERICA. 
The credit for the first removal of the uterus per vaginam for malignant 
disease in this country, so far as I am able to learn, is due Professor Paul 
F. Eve, of Augusta, Ga., who, on April 16, 1850 ("Am. Jour, of the Med. 
Sciences," 1858), did vaginal hysterectomy for extensive malignant disease 
of the uterus and vagina-at that time diagnosticated as encephaloid. This 
operation was done in the presence of Dr. J. A. Eve, Dr. Longstreet, Dr. 
Montgomery, and Dr. Henry Campbell, and to the latter I am indebted 
for an accurate description of the case and operation. 
The patient, a negress, twenty-eight years old, had been married, but never 
impregnated. Her disease had existed for three years, attended by frequent 
haemorrhages from the vagina. She was placed under chloroform, in the lith- 
otomy position, and the growth seized with forceps, which repeatedly gave 
way, bringing with it large masses of necrosed tissue. Finally the growth was 
dragged down to the ostium vaginae, and, finding it impossible to remove the 
firm resisting body, it was carefully excised with a knife, from above down- 
ward, or in an antero-posterior manner. The left uterine artery, which bled 
quite profusely, was ligated with animal ligature. A solution of sulphate of zinc 
was applied to restrain further haemorrhage, which had been considerable. 
There was no protrusion of the bowel, or other severe symptom, following this 
operation. In the mass removed the uterus was readily recognized, with its 
Fallopian tubes and round ligaments. The patient returned to her home on the 
seventeenth day, and on June 15th, two months after the operation, rode eleven 
miles to see the doctor, who found the disease returning in the vaginal wall. 
She died from haemorrhage three months and one week after the operation. 
Such is a brief history of the first case of vaginal hysterectomy in the 
United States for malignant disease. But this, it seems, was not the first 
time the uterus was removed per vaginam successfully, although not for 
malignant disease, for I find that as early as September, 1834, Dr. John M. 
Esselman, of Nashville, Tenn., successfully removed the inverted uterus 
by means of the ligature, and his patient made a good recovery. He again 
did the operation successfully in August, 1843, for inverted uterus con- 
taining a fibroid. Others followed his example with success. From 1850 
to 1878, a period of twenty-eight years, I am unable to find recorded a 
single case of complete removal of a cancerous uterus per vaginam. 
During that time in this country the fashionable method of operating 
seems to have been by abdominal section, and numerous cases are tabulated 
of removal of the uterus, or the corporeal portion of it, for malignant dis- 
ease or fibroid. As early as June 25, 1853, Dr. Walter Burnham, of 
Lowell, Mass., operated by this method, followed by Dr. Gilman Kimball, 
of the same city, in August of the same year. At the end of the period 
mentioned, on January 30, 1878, Freund's operation, with the history of 
which you are all familiar, was given to the profession. Numerous cases of 
it are recorded, but death followed so closely in its wake that I hasten to 
dismiss it from my subject; and, as it is the purpose of this paper to speak 
of vaginal hysterectomy for malignant disease only, I will simply give a 
passing notice to the removal of the uterus by other methods. VAGINAL HYSTERECTOMY IN AMERICA. 
11 
On October 17, 1876, Dr. Emil Noeggerath, of this city, reported a case 
before the New York Obstetrical Society (see page 150, " Trans.," '76 and 
'78), entitled "A New Operation for the Removal of the Uterus with its 
Peritoneal Envelope through the Vagina for Carcinoma," which he stated 
was the first operation of the kind. Undoubtedly it was, and has remained 
so ever since, for the operation was never finished. A word of explanation 
for this remark is necessary and just: 
The operation was undertaken per vaginam. The anterior and posterior 
vaginal connections were severed with the galvanic knife, the openings thus 
made were stretched with an Ellinger's dilator, and the finger was passed into 
the pelvic cavity to examine the broad ligaments. They were found to be hard 
and infiltrated, rendering extraction by the vagina difficult. The abdominal 
cavity was therefore opened through the linea alba, Plan's wire constrictors 
were passed in and the broad ligaments and tubes constricted ; then the abdomi- 
nal incision was closed. (This procedure at once excludes this operation from 
my list of purely vaginal ones.) 
The patient died of septicaemia on the fourth day. An autopsy showed the 
uterus in situ, although nearly severed from its ligamentous attachments by the 
constricting wires. 
The operation will pass into history as an uncompleted procedure, and 
I must look in another direction for the next successful case of vaginal 
hysterectomy in the United States. 
This I find to be credited to Dr. L. C. Lane, of San Francisco, who, 
on the 11th day of November, 1878, did the operation for epithelioma of 
the cervix, and repeated it the same year. His method of operation I shall 
speak of farther on. I can find no report of its having been done again 
until January 28, 1880, when it was performed by Blake, of Boston, whose 
patient died in twelve hours from shock. The next to perform it was 
Cushing (September 4, 1881), of San Francisco, followed in a few days by 
Anderson and Taylor, of San Francisco, and Fenger, of Chicago, with suc- 
cessful results. Up to this time, you can see, the western part of our 
country took the lead. Then surgeons in the East resorted to the opera- 
tion, and during the year 1882 six operations were done by as many 
operators, the result being a loss of five of the patients. In 1883 eight 
patients were operated upon by seven different operators with a loss of 
two. In 1884 eight operations were done by six operators, the result 
being one death, so that from November, 1878, to the first of the year 
1885, thirty operations had been done, resulting in death in ten. 
I have records of fourteen operations that were done during 1885, 
nearly half the number of all those done in the previous years I have men- 
tioned. Of that number, eight ended fatally, and, with the exception of 
Lane', Munde', and Weir', they were the operators' first and only cases. 
But do not hasten to condemn this operation on that account. One who 
has tried it knows the difficulties he has to surmount, and no one can appre- 
ciate them until he has done it himself; and when he has, almost his first 
thought will be, I can do it better the next time. VAGINAL HYSTERECTOMY IN AMERICA. 
12 
The record for 1886 seems to confirm this statement, for of the twenty- 
one cases for that year, of which I have a record, with the exception of 
three, whose cases were all successful, the operation was done by old opera- 
tors, and of the twenty-one, five resulted fatally. This is a material in- 
crease over the records of the previous years, and evidences either an 
improvement in manipulative skill, or more careful choice of cases selected 
for operation. Of the sixty-six cases I have collected which are shown 
in the table, twenty-three resulted fatally, while forty-three patients re- 
covered and remained well afterward for periods varying from three months 
to three years (see table). The variety of disease for which this operation 
has been resorted to most frequently in this country has been epithelioma 
of the cervix uteri. 
It is difficult to tabulate the exact number of each form of the dis- 
ease, for, while one operator in his report speaks of his case as carcinoma 
of the cervix, another describes it as cauliflower, and still another as 
epithelioma, without going into details sufficiently to be positive. Of 
the sixty-six cases I have collected, thirty-three are designated epithelioma 
involving the cervix and extending into the body to a more or less degree. 
Only four cases are diagnosticated as carcinoma of the body, three as 
sarcoma of the cervix, and only one as sarcoma of the body-evidence of 
a much more frequent occurrence of the epithelial form of the disease. 
The methods of operation practiced by the operators of this country 
differ but slightly in their essential points. In the cases reported, two 
thirds of the surgeons have preferred the lithotomy position for the 
patient, while the remaining third have employed the Sims position. 
The choice as to opening the anterior or posterior cul-de-sac first has been 
about equally divided, while in the large majority of the cases the uterus 
has been retroverted for the purpose of bringing it into the vagina, and the 
broad ligaments have been tied in sections. Open dressing of the wound 
is the accepted method, iodoform gauze being used as an application to 
the cut surfaces, applied in the form of a loose tampon, and allowed to 
remain for several days, unless contra-indicated by a rise of temperature. 
Such is the method practiced by Dr. Lane, of San Francisco, who stands at 
the head of the list of operators, in point of number, having done nine 
operations, with a loss of three patients, while Dr. Bernays, of St. Louis, 
although second in point of number, heads the list of successful operators, 
having done six operations without a death. 
Dr. Polk, of this city, favors the dorsal position, and, as his method 
differs so materially from that practiced by others, I desire to mention the 
essential steps taken in its performance. The patient on the back, he 
divides the vaginal mucous membrane into the cellular tissue on the sides 
first, preferably with the galvano-cautery, then through these openings he 
passes his modified aneurysm-needle, hooks down the uterine arteries and 
ligates them before cutting farther. The anterior and posterior vaginal 
wall are then treated in the same manner. When this has been done the VAGINAL HYSTERECTOMY IN AMERICA. 
13 
patient is ready for the second step in the operation, which is a supra- 
vaginal amputation of the cervix. He then has only loose cellular tissue 
and peritonaeum to deal with. Before opening the latter, the vagina is 
thoroughly cleansed with an antiseptic solution. This being done, the 
peritonaeum is opened, and the remaining portion of the body is anteverted 
or retroverted, as the case may indicate. The ovarian arteries are then 
ligated, including as much of the tubes and ovaries as possible. The space 
then remaining between the uterine and ovarian arteries is ligated en masse, 
and small bleeding points in Douglas's pouch are ligated separately. No 
portion of the wound is closed by suture and no drainage-tube is used, but 
the wound is packed with iodoform gauze. In view of the good results 
obtained and reported by Dr. Baker at a previous meeting of this society, 
the question might be raised as to why the doctor should open the peri- 
tonaeum and remove the remaining portion of the body after having done 
so thorough a supra-vaginal amputation without loss of much blood. 
Opinions concerning the operation differ but slightly among the opera- 
tors of the United States. It is the universal opinion that it is limited 
to certain forms of the disease-namely, carcinoma of the body and epi- 
thelioma of the cervix, neither of which shall have advanced sufficiently 
to have involved the peri-uterine structures, and that the organ shall be 
perfectly movable. Dr. Hunter and Dr. Bull, of this city, believe this 
operation the best that can be chosen for the class of cases I have men- 
tioned. 
My own experience has been limited, but peculiar features of interest 
have attended it, and I have taken pains to follow the cases closely to their 
termination, and will report their results in full. My first was- 
Vaginal Hysterectomy ; Recovery. Entero-vaginal Fistula Six Months La- 
ter; Laparotomy for its Relief.-Mrs. G., aged forty-six, married thirty years, 
and the mother of six children, the last two years old; two miscarriages since 
the birth of the last child, caused by taking rhubarb ; menstrual function always 
regular, but profuse, with some pain during the flow; menopause six months 
previous. Her general health was poor, and she was thin and ansemic. Her 
present illness had lasted nine months. It began with pain of a lancinating 
character in the back, lower part of the abdomen, and vulva, radiating into the 
thighs and legs. The pain was increased by standing or walking. Local exami- 
nation revealed epithelioma of the cervix uteri, extending into the cervical canal, 
and also involving the vaginal wall slightly on the right side. The uterus was 
perfectly movable, and she had not suffered from haemorrhage. The patient's 
condition called for removal of the diseased tissues without delay. Removal of 
the uterus per vaginam was proposed, and on December 20, 1883, the operation 
was performed in the following manner: The patient was given an anaesthetic 
composed of equal parts of methylene and ether, and placed upon the left side 
in Sims's position. A large Sims's speculum was introduced, and the bladder 
was emptied and held forward against the pubes by a Peaslee's sound. I then 
grasped the cervix with a volsella, and carried it backward toward the posterior 
vaginal wall, thereby tilting the body of the uterus forward, and putting the 
anterior vaginal wall upon the stretch. The forceps being held by an assistant, 14 
VAGINAL HYSTERECTOMY IN AMERICA. 
the vaginal wall immediately in front of the cervix was caught up upon a tenac- 
ulum, and, keeping the cervix as a guide, a semicircular incision, about an inch 
and a half long, was made with a sharp knife, the cut being continued until the 
peritonaeum covering the utero-vesical fold could be felt, and this also was 
caught up and cut with 'blunt-pointed scissors. The finger could now be readily 
passed to the fundus of the uterus, and swept along each broad ligament. Still 
retaining my finger within the incision already made, I introduced by the side of 
it the long handle of a scalpel, and gradually enlarged the opening by a process 
of scratching until it extended in a half-circle around the cervix to each broad 
ligament. Then, firmly fixing one blade of a volsella in the fundus, I made 
gradual traction forward, at the same time pressing the cervix back in the vagina 
until the fundus appeared at the opening, and was grasped with a catch forceps. 
The difficulty now arose of drawing the fundus into the vagina, but, by steady 
traction and using my thumb and finger, I was able (so to speak) to put the cut 
surface back over the fundus, and bring the latter into the vagina with little 
difficulty. A thin, flat sponge was then secured by silk, and passed into the 
pelvic cavity to protect the intestines. The patient being on the left side, the 
left or lower broad ligament was first ligated, including the ovarian artery, and 
was divided down to the vaginal roof, the uterine artery of that side still remain- 
ing untied. The uterine surface of the cut was secured by clamp forceps. The 
right ligament was treated in the same manner, and was severed down to the 
neighborhood of the uterine artery. The uterus was now perfectly movable, 
and I was able to readily pass a curved needle through Douglas's cul-de-sac at 
each side of the cervix, and to ligate the uterine arteries. This accomplished, 
both broad ligaments were entirely severed, and the uterus was separated from 
its attachment to Douglas's cul-de-sac and removed. The vagina was then 
thoroughly cleansed with a solution of bichloride of mercury, 1 to 3,000, and 
the cut surfaces were inspected to be sure that all diseased tissue had been re- 
moved. Several small points of indurated tissue were found. These were 
removed, including some of the apparently healthy tissue, until the whole cir- 
cumference of the cut surface felt soft to the touch. This started afresh the 
haemorrhage from the small vessels of the vaginal walls. These I did not at- 
tempt to ligate, as it is quite difficult to do properly, and takes much valuable 
time. The bleeding points were caught by small torsion forceps, which were 
allowed to remain until the next morning. The sponge was next removed from 
the pelvic cavity, and the latter was thoroughly cleansed with a solution of 
bichloride and sponged dry. The intestines could be seen lying high in the 
cavity, away from the pelvic roof. Another sponge was then introduced into 
the vagina and placed in apposition to the cut surface, and the patient was put 
to bed. The time of operation was one hour and forty minutes. The sponge 
was removed on the same evening, and the forceps the next morning. No 
haemorrhage followed. The patient's recovery was facilitated by sufficient mor- 
phine to relieve pain, together -with perfect cleanliness. The urine was drawn 
every six hours, and the vagina washed out with a solution of bichloride, 1 to 
3,000. The bowels were first moved by enemata on the sixth day, and each day 
after that either by oil or enema. The daily temperature ranged from 100° to 
102° F., and the pulse from 100 to 110. The ligatures were removed on the 
thirteenth day. Twenty days after the operation the patient sat up several 
hours. Twenty-six days after the operation, examination showed union per- 
fect, and she was discharged well. VAGINAL HYSTERECTOMY IN AMERICA. 
15 
T am well aware that vaginal hysterectomy for cancer is an operation 
not yet accepted by a majority of the profession as a justifiable procedure, 
and it is only by tracing such cases to their final termination that their 
histories become of any value in enabling us to draw just conclusions con- 
cerning such operations. This I have endeavored to do in the present case, 
and for a concise record of the patient's condition from the time she left 
the hospital until her death I am indebted to Dr. II. W. Smith, of Placer- 
ville, California, who kindly furnished me with the following history: 
The operation was performed in December, 1883, and she remained in good 
health until the following June, when, while making beds one day, she felt 
something suddenly give way in the lower part of the abdomen, and immediately 
began to have pain. She was then under the care of another physician. On 
July 28th she was seen by Dr. Smith in consultation, at which time she had 
stercoraceous vomiting, and all the symptoms of complete obstruction of the 
bowel. Examination per raginam revealed a hardened mass in the pelvis in 
about the position that the body of the uterus should have occupied. The doc- 
tor does not state the method of treatment adopted at that time. He did not 
see her again until the following November. During the interval the intestine 
had sloughed, and a fistulous opening into the vagina had formed so that the 
contents of the bowels passed entirely through this opening, which readily ad- 
mitted the passage of a large sound into the intestine. Very little cicatricial 
tissue surrounded the fistula. In November she placed herself under Dr. Smith's 
care, and desired an operation for closure of the fistula. At that time her gen- 
eral health was much improved, but she was mentally depressed, owing to her 
failure to secure permanent relief. At that time Dr. Smith scraped away some 
of the raw edges of the fistula, and, after submitting it to microscopical exami- 
nation, declared it to be non-malignant; but, finding some hard lumps in the 
region of the ascending colon, he thought that possibly the growth had re- 
turned higher up in the pelvis, and that the lumps felt might be infiltrated 
glands. But, after one month's observation, with repeated examinations, and 
finding no change in her condition, he consented to operate for closure of the 
fistula. December 13, 1884, she was again placed under an anaesthetic, and, 
assisted by Dr. Cook and Dr. Stone, he made an incision through the linea alba 
five inches and a half long. The abdominal contents were examined, com- 
mencing at the stomach and following the intestine down to its obstruction, 
which was found to be eight inches from the ileo-caecal valve. The ileum 
was twisted upon itself in a half-figure-of-eight manner, and bound down in 
Douglas's cul-de-sac by bands of plastic lymph, the remains of a former peritoni- 
tis. The portion of the ileum from the stricture to the colon had atrophied, 
and was no larger than a lead-pencil. The vermiform appendix was attached 
to the right broad ligament by plastic bands. 
After thoroughly examining the pelvis by conjoined manipulation, the doctor 
states positively that there was no return of the cancer present, and that the 
lumps felt were faecal concretions in the ascending colon. The intestines were 
normal except the atrophied portion, through which nothing had passed for 
six months. The spleen, kidneys, and liver were normal. After this thorough 
examination of the abdominal organs, the intestines were drawn up, and, after 
squeezing the faecal concretions from the caecum, the ileum was united to the 
ascending colon, just above the ileo-caecal valve, by the Lembert stitch, the KJ GINAL HYSTERECTOMY IN AMERICA- 
16 
serous surfaces being carefully brought together and the muscular coats being 
included in the stitches. Fine silk was used for sewing the gut together. After 
all the oozing had stopped, he closed the abdominal incision with silver-wire 
sutures, applied antiseptic dressings, and put the patient to bed. She reacted 
well after the operation, and in six hours flatus escaped from the rectum by 
passing a catheter, and for three days her condition was very favorable. Dur- 
ing the third night she had a natural passage from the bowels, the first in 
six months. Her temperature ranged from normal to 101 *5°, and her pulse 
from 112 to 128. There was no tympanites until the initiatory chill of peritoni- 
tis, from which she died on the morning of the fifth day, one year after the first 
operation. 
There are several interesting features in this case, which may be 
summed up as follows: 
1. The advance which the disease had made before the operation was 
resorted to. The cervix was so much involved that it broke down when 
grasped by the forceps, and the right wall of the vagina also was somewhat 
affected. Still, at the expiration of one year, no return had manifested 
itself. (In an article entitled "The Limitation of Vaginal Hysterectomy," 
read before the American Gynaecological Society in 1884, by Dr. Paul F. 
Munde, he gives statistics of eighty-two operations, in thirty-two of which, 
or 39'2 per cent., the patients remained free from recurrence two years 
after the operation.) 
2. The manner of operation. From what I can gather from the litera- 
ture of the subject (especially from the German), the usual position for 
operation is upon the back. Both anterior and posterior vaginal con- 
nections are severed, and the uterus is retroverted and brought into the 
vagina. It seems to me that the lateral (Sims's) presents many advantages 
over the dorsal or lithotomy position. In the former, fewer assistants and 
instruments are required to keep the parts in view, and the haemorrhage 
can be much better controlled, while the blood, escaping from the most 
dependent portion of the vagina, does not obstruct the view of the parts. 
Dr. Munde, in summing up the report of his cases, stated that in the future 
he should operate with his patient in the gluteo-dorsal position in prefer- 
ence to the Sims, his main reason being the difficulty of doing the opera- 
tion in case of narrow vagina. I can not see the advantage of the dorsal 
position, with the numerous retractors, even under such circumstances, for 
the narrow or contracted condition of the vagina can be largely overcome 
by thoroughly packing it with antiseptic cotton for a few days before the 
operation. 
3. With the patient in the dorsal position, one of the most trouble- 
some features of the operation is to keep the intestines and bladder out 
of danger. In Sims's position both bladder and intestines are carried out 
of the way by force of gravity, and thus are Jess liable to be wounded. 
Again, by anteverting the uterus and drawing it down, while the posterior 
vaginal connection still remains intact, there is less liability of necrosed VAGINAL HYSTERECTOMY IN AMERICA. 
17 
tissue and poisonous fluids coining into contact with the intestines or 
pelvic peritonaeum, while the danger of concealed haemorrhage from 
bleeding vessels behind the Sims speculum (as happened in Dr. Mundb's 
case) is avoided; and certainly, after the uterus has been removed, the 
operator is better able to detect any portions of diseased tissue which may 
not have been included in the first incisions. 
These advantages of the side position tend to shorten considerably the 
actual time required to perform this operation, which is an item worth con- 
sidering. In my own case, although the woman had borne children, the 
vagina was not voluminous; still, the operation was completed without haste 
in one hour and forty minutes. 
4. As to the best method of leaving the wound after operation. In 
this case I did not close any part of the wound with sutures, but left it 
to heal by granulation (and how far may this method have been the cause 
of the inflammatory adhesions which resulted in obstruction of the bowel 
and production of the fistula?), which is a rare occurrence after such an 
operation. Martin, in his last work, reports sixty operations for various 
forms of disease (carcinoma, sarcoma, epithelioma, and adenoma), in one of 
which an entero-vaginal fistula resulted, but in that case the cancer had 
involved the tissues around the uterus. His method of treating the wound 
is by closely uniting the peritonaeum and the vagina with interrupted sutures, 
applied with a sharply curved needle, the application of the sutures follow- 
ing closely upon each incision so as to avoid haemorrhage. They are passed 
through the vaginal wall and peritonaeum, returning on the same side so 
as to ligate all bleeding vessels, and at the same time fasten the perito- 
naeum around the circumference of the wound. The angles of the wound 
are then brought together with interrupted sutures. He concludes that a 
drainage-tube is necessary for a good result, and uses the soft rubber 
tubing. At stated intervals he cleanses the vagina, but does not inject 
water into the peritoneal cavity. The cut surfaces heal by granulation, and 
he afterward removes the peritoneal-retaining sutures carefully. In my 
case, as before stated, the wound was left to heal by granulation at the 
same time that free drainage was secured, and it healed perfectly in twenty 
days. The surgeons who have done vaginal hysterectomy have each his 
own peculiar way of treating the wTound after operation. While one 
stitches the wound closely around a drainage-tube, another is content to 
leave the wound to heal by granulation. But, as statistics show a decrease 
of mortality in proportion to the increase of our knowledge of antiseptic 
surgery in this operation as well as in others, the main feature of the after- 
treatment proves itself to be antisepsis, and for statistical evidence of this 
fact the reader is referred to a valuable paper by Dr. Sarah Post in the 
"American Journal of the Medical Sciences" for January of the past 
year. 
5. This case is also of interest because it demonstrates how the intes- 
tines may be treated, in accidents to the latter, during or following such VAGINAL HYSTERECTOMY IN AMERICA. 
18 
operations or abdominal section for any purpose, even after a lapse of six 
months, without a proper movement. 
Since writing the preceding portion of this paper I have done the 
operation a second time, and, although not with such good success (it 
having terminated fatally), I desire to place a short report of it before you, 
in order to call your attention to some features of the case which to me 
have been most instructive. 
The patient was Mrs. Marie B., German, aged forty-eight years, married 
twenty years, the mother of ten children ; no miscarriages ; widow eight years 
With her first four children she had a physician ; the last six a midwife was in 
attendance. She ceased to menstruate at the age of forty-five, and remained 
well for nearly two years. Then she commenced to have pain through the back 
and pelvis, which continued until the time I saw her. For the last five months 
it had been severe, and accompanied with frequent haemorrhages per raginam. 
She first came to my clinic at the Northeastern Dispensary, December 20, 1886, 
when I made a diagnosis of malignant disease of the uterus, involving the cervix 
and extending into the body. I sent her to the Post-graduate school, where 
Professor Bache Emmet confirmed my diagnosis. She was admitted into the 
hospital on the 26th, and on the morning of the 28th of December the operation 
was done. During the two days that she bad been in the hospital the vagina 
had been packed as closely as she could bear with an iodized glycerin tampon. 
This served to prevent haemorrhage, remove the bad odor, and dilate the vagina 
to a considerable extent. 
The operation was done in the same manner as described in the previous case, 
excepting that after opening the anterior cul-de-sac I took the precaution to 
ligate each uterine artery before attempting to autevert the uterus. My 
trouble then commenced, for as I passed my finger over the fundus uteri I 
discovered that it contained a small fibroid in each horn, which widened the 
surface to such a degree as to make it impossible to bring the body of the uterus 
into the vagina. I anteverted it and brought the right horn, containing the 
largest fibroid, into the vagina, transfixed and ligated beneath the fibroid, and 
cut the latter away. I then allowed the uterus to fall back into the pelvis, 
turned it upon itself, and brought the left horn down, and soon succeeded in 
bringing the body through the incision into the vagina, but in my efforts to 
do this I lacerated the tissue considerably by making too much traction with 
the forceps. This promoted considerable bleeding from the left ovarian artery, 
which 1 readily controlled by casting the elastic ligature around the body close 
to the vaginal junction. Finding I had perfect control of all haemorrhage, 
which facilitated my work, I again severed the body close to the ligature. Up 
to this point the operation had been very difficult, and much time had been 
consumed owing to the fact that the vagina was narrow, making work exceed- 
ingly difficult; and this difficulty was further complicated by a whip-cord-like 
band of peritonaeum, which extended from the lower and posterior surface of 
the right broad ligament up the side of the pelvis to the true pelvic brim. This 
hand prevented my being able to draw the uterus down more than an inch, 
and obliged me to do the entire operation with it high in the pelvis. Having 
removed the major portion of the body, I transfixed and again ligated each 
broad ligament, slipped my elastic ligature, and cleared the remaining portion VAGINAL HYSTERECTOMY IN AMERICA. 
19 
of the uterus from the vagina. The small sponge, placed in the pelvis after 
anteverting the uterus, had prevented any blood entering among the intestines. 
The vagina was thoroughly cleansed, the sponge carefully withdrawn, and the 
wound filled with iodoform gauze. The patient went to bed with a weak pulse, 
but responded readily to stimulants and reacted rapidly, so that by 8.30 p. m. 
the pulse was good at 90, and the temperature 99'6°. She was given hot water 
to drink, with brandy as a stimulant, and passed a very comfortable night. The 
urine was drawn every four hours, about two ounces being obtained each time. 
At 11 a. m. the next day, the pulse and temperature having gone up rapidly since 
morning, I feared haemorrhage into the pelvis and removed the tampon, but 
found the latter sweet and no evidence of bleeding. I then passed the catheter 
and got no urine. Wondering what the cause could be, I was informed by 
the house surgeon that he got but very little from the last passage of the cathe- 
ter. Our efforts were then directed toward reducing the temperature and 
relieving the kidneys. The former I succeeded in with hypodermic injections 
of hydrochloride of quinine and urea and the application of the cold-water 
coil; but, although twenty minims of tr. digitalis and twenty grains of bromide 
and acetate of potassium were each given every hour, with hypodermic injec- 
tions of brandy as a stimulant, the kidneys would not respond, and the pulse 
gradually weakened and ran higher until death took place thirty-eight hours 
after the operation. 
After much persuasion, permission for an autopsy was obtained, and Pro- 
fessor Porter, pathologist to the school, kindly furnishes me with the following 
excellent report: 
The necropsy, which was limited to the abdominal cavity, was made about 
twelve hours after death. The peritonaeum was carefully examined and found 
to be absolutely free from any inflammatory action. The pelvic cavity con- 
tained no blood or serum, and the stump of the operation was free from suppu- 
ration and in a reparative condition. 
The spleen was small and fissured, but otherwise normal. 
Kidneys.-Both glands were enlarged, weighing six ounces (170 grammes) 
each. They were soft and of a whitish-yellow color. Their capsules were non- 
adherent to the underlying renal tissue, the surface of which remained perfectly 
smooth after enucleation. The mucous membrane in both pelves presented a 
marked congestion and puffiness, which would indicate the existence of an acute 
pyelitis. 
The cut surface of the glands showed the cortex to be thickened, pale, granu- 
lar, and fatty, but the markings were straight. Upon microscopical examination, 
the epithelium of the uriniferous tubules was found to be in a state of granular 
and fatty metamorphosis, many of the tubules being occluded by the desquama- 
ting epithelium, hyaline, finely and coarsely granular and fatty casts. There was 
no inflammatory change and no active change in the intertubular tissue; but the 
appearances were those of a rapidly progressing acute parenchymatous meta- 
morphosis of the kidneys, which had existed for a day or two only. The few 
drops of urine obtained at the time of the necropsy gave every evidence of the 
existence of the above lesion. A small lipoma projected from the surface of 
one kidney. 
This form of renal lesion is of comparatively frequent occurrence in 
connection with severe surgical operations, and explains many of the so- 20 
VAGINAL HYSTERECTOMY IN AMERICA. 
called septic symptoms without suppuration, the erroneously named septic 
symptoms being due to a uraemic toxaemia from non-elimination. 
The liver was the seat of a marked interlobular cirrhosis. There was a small 
lipoma in the omentum, near the splenic flexure of the colon, that had under- 
gone fibrous and cavernous metamorphosis. Sections made from the uterine 
neoplasm were found to be composed largely of fibrillated connective tissue 
and non-striated muscle fibers. In some places this mixed tissue contained rings 
of cylindrical epithelium, commonly described as the cauliflower growth, or 
cylindrical-celled epithelial carcinoma, while in other sections the perivascular 
or lymphatic spaces were dilated into alveolar cavities, and were packed full of 
irregular epithelial cells without intercellular substance, and without any definite 
order of arrangement, this appearance being that characteristic of a scirrhous 
carcinoma. 
For a full description of the pathology and development of this form 
of renal lesion the reader is referred to Dr. Porter's work, published by 
William Wood & Co. REASONS WHY 
Physicians should Subscribe 
-FOR- 
The NewYork Medical Journal, 
Edited by FRANK P. FOSTER, M. D., 
Published by D. APPLETON & CO., 1, 3, & 5 Bond St. 
1. BECAUSE : It is the LEADING JOURNAL of America, and 
contains more reading-matter than any other journal of its class. 
2. BECAUSE : It is the exponent of the most advanced scientific 
medical thought. 
3. BECAUSE : Its contributors are among the most learned medi- 
cal men of this country. 
4. BECAUSE: Its "Original Articles" are the results of sci- 
entific observation and research, and are of infinite practical 
value to the general practitioner. 
5. BECAUSE: The "Reports on the Progress of Medicine," 
which are published from time to time, contain the most recent 
discoveries in the various departments of medicine, and are 
written by practitioners especially qualified for the purpose. 
6. BECAUSE: The column devoted in each number to "Thera- 
peutical Notes " contains a resume of the practical application 
of the most recent therapeutic novelties. 
7. BECAUSE : The Society Proceedings, of which each number 
contains one or more, are reports of the practical experience of 
prominent physicians who thus give to the profession the results 
of certain modes of treatment in given cases. 
8. BECAUSE : The Editorial Columns are controlled only by the 
desire to promote the welfare, honor, and advancement of the 
science of medicine, as viewed from a standpoint looking to the 
best interests of the profession. 
9. BECAUSE : Nothing is admitted to its columns that has not 
some bearing on medicine, or is not possessed of some practical 
value. 
10. BECAUSE: It is published solely in the interests of medicine, 
and for the upholding of the elevated position occupied by the 
profession of America. 
Subscription Price, $5.00 per Annum. Volumes begin in January 
and July.