Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Vol. XXVII., Nos. 4-5, 1893.] 
tOLN-USIIKCTOU FOR IULIHMI HIM. 
SOME CONSIDERATIONS IN REGARD TO THE OPERATION, 
TECHNIQUE, ETC. 
WITH A REPORT OF MY FIRST FIVE CASES.1 
By MARY A. DIXON JONES, M.D., 
Brooklyn, N. Y. 
These five operations were performed in 188J. I have pur- 
posely delayed reporting them,1 to see what time would prove as 
to the results. Many women had previously consulted me for 
cancer of the uterus ; some I tried to help ; yet for none did I 
consider a radical operation advisable, except one patient, in 
December, 1883, I hoped might be saved ; but further investi- 
gation proved that the disease had extended beyond the uterus 
and that other structures were involved. Greig Smith,8 in dis- 
cussing the indications for colpo-hysterectomy, gives the follow- 
ing rule : “The patient must be in fair health; marked anemia, 
cachexia, or a faulty condition of the vital organs forbids opera- 
tion.” By this, certainly, these patients were condemned. So, 
indeed, were all those whose histories are given below. All had 
marked anemia, all were cachectic, all had a faulty condition of 
the vital organs, and each of them had been out of health for a 
considerable period. Only the third case gave promise of ulti- 
mate recovery ; the operation, for the others, was undertaken as 
a last resort, with almost a fear that they could not survive, but 
it was the only thing that gave the least prospect of saving their 
lives or lessening their sufferings. 
Case I.—Mrs. K. called at Fleet Place Dispensary May 30th, 1887. She 
was 62 years of age, married thirty-one years, and had four children, the 
youngest 19 years old ; said she had not been well since the birth of this 
child. Menstruation appeared at the age of 16, was regular, stopped at 44, 
reappeared at 48, and for the last few months there had been a constant 
bloody and watery discharge. The patient was feeble, emaciated, no appe- 
tite, suffered great pain, and asked to be admitted to the hospital. Carci- 
noma of the uterus was diagnosed, and, as far as I could judge, the cancer 
1 The specimens were presented before the New York Pathological Society. 
2“ Abdominal Surgery,” p. 214. 2 
JONES : COLPO-HYSTERECTOMY 
had not invaded the surrounding tissues, so if the operation was performed 
without delay there might be hope. I determined to save the woman if 
possible. On the 4th of June, 1887, assisted by Dr. Charles N. D. Jones, I 
removed the entire uterus. First the cancerous tissue was curetted away, the 
parts cleansed and disinfected, and a circular incision was made around the 
cervix ; I then separated the vaginal tissues, keeping close to the uterus, 
opened into the peritoneal cavity anteriorly and posteriorly, tied the broad 
ligaments on each side, and delivered without retroversion or anteversion. 
The vagino-peritoneal wound was left unclosed and the vagina packed with 
iodoform gauze. The patient made an excellent recovery ; her temperature at 
no time was above F. At the end of two and one-half weeks she was 
able to be up, had a good appetite, and gained in health and strength. No- 
vember 12tli, 1887, she says she is better and more comfortable than she has 
been for many years. Fourteen months after the operation she was enjoying 
comparatively good health and able to do her usual amount of work. For a 
while we heard from her occasionally ; each time she was doing well. After 
this the patient disappeared from view ; still, by the operation she was re- 
lieved of suffering and restored to comparative health and vigor. 
Case II.—Mrs. E. first consulted me July 22d, 1887, at the Throop Avenue 
Dispensary ; she was 49 years of age ; married eighteen years ; had nine chil- 
dren, the youngest 11 years old ; says she has been sick since the birth of this 
child, and now complains of pain in her back, severe shooting and darting 
pains through the pelvis, and the last few months has had a profuse watery 
and bloody discharge. 
I found a deeply lacerated cervix in a state of ulceration, and from it was 
issuing an offensive flow streaked with blood and coming away in immense 
quantities. I excised a few granulations from the cervix, and sent them to 
Dr. C. Heitzmann for microscopical examination. He pronounced it to be a 
small round-celled sarcoma, and said that the patient would probably not live a 
year. I informed the patient and her husband, and told them that nothing 
would save her but entire extirpation of the uterus. They were both extremely 
anxious that the operation should be performed. I delayed from time to time, 
because I felt extreme hesitation in attacking a disease so threatening and so 
far advanced, lest the patient might not eventually be benefited. Finally, 
September 5tli, 1887, she was admitted into the Hospital for Women at 501 
Madison street. 
From further investigation I had reason to believe that the disease had not 
only extended to the fundus, but had invaded the surrounding structures. I 
requested Drs. H. J. Boldt and A. P. Dudley, of New York, to see the patient. 
Aftercareful examination they were both of the opinion that “the disease 
had extended beyond the uterus,” but still thought it “ a suitable case for 
operation.” Subsequently I found even more serious symptoms, and, fearing 
the worst results, said to the husband and wife that even entire extirpation of 
the uterus might not cure, and that the patient had better be removed from 
the hospital and have nothing more done. I insisted upon this more espe- 
cially on account of her emaciated and exhausted condition, which gave little 
hope of final recovery. Both husband and wife seemed to become more and 
more anxious for the operation, and urged persistently that it be performed ; 
she especially pleaded that it might be done—“even if there was but one 
chance in a hundred, she wanted that chance.” 
If the operation would give the woman a chance of life, why should I not FOR MALIGNANT DISEASE. 
3 
make the effort? The womb was fairly movable; possibly she might be saved. 
On the 8th, as exploratory and preparatory for the operation, 1 scraped and 
curetted away as much as possible of the malignant growth, which seemed to 
have honeycombed the whole anterior part of the cervix and extended into the 
fundus. A considerable amount was curetted out, the cervix and vagina were 
disinfected and tamponed with iodoform gauze. 
The patient did not stand this operation very well. She was evidently fail- 
ing very rapidly and there was no time to lose. On the 18th I had the patient 
etherized and performed for her vaginal hysterectomy. The uterus was pulled 
down with volsella forceps, the extent of the bladder carefully noted, and 
near it an incision was made anteriorly in the mucous membrane covering the 
cervix, and as far as possible from the seat of the ulceration. I then separated 
the bladder and vaginal tissues, keeping close to the uterus to avoid any injury 
to the bladder. I opened into the peritoneal cavity anteriorly. Enlarging this 
opening, I passed the index finger of my left hand to the fundus of the uterus 
and out on the left broad ligament, which I secured, at the top part by liga- 
tures aud the lower portion by forceps, then separated, removing a consider- 
able part of the broad ligament, so as to get clear of any possibly infected 
tissue. The fundus was next partially delivered anteriorly, the right broad 
ligament secured in the same manner, at the top with ligatures and the lower 
portion by long-bladed forceps. I also removed from each side a considerable 
portion of the broad ligament and as much as possible of the parametric cellu- 
lar tissue. The blood vessels of the pampiniform plexus were numerous and 
enormously enlarged. 
The uterus was now completely delivered, held only by posterior connections 
which were readily separated, and hemorrhage was prevented by pressure 
forceps. The operation was finished in an unexpectedly short period. The 
sponges which had been previously introduced to keep the intestines back, and 
which served to protect the peritoneal cavity, were now removed, and thereby 
the cavity was still further cleansed, and any hemorrhage guarded against by 
putting on more pressure forceps and then packing with iodoform gauze. No 
attempt was made to sew up the vaginal wound. I made the end of a strip of 
gauze enter a little into the peritoneal cavity to se'cure more perfect drainage. 
The seat of the operation, with the hanging forceps, was fully surrounded and 
protected by an abundance of absorbent cotton, and the patient placed in bed. 
She came out of ether feeling quite comfortable—so comfortable that she 
asked me during the evening if I had really removed the uterus or had per- 
formed any operation. When I assured her the operation had been performed 
and the uterus was removed, she was satisfied, happy, and very cheerful. The 
same evening she micturated and had a natural evacuation from the bowels, 
The dressings were changed and the patient slept comfortably the whole night. 
During the second day she took nourishment, had a good appetite, asked for 
grapes, and repeatedly expressed satisfaction that the operation had been per- 
formed. Her pulse was 108, temperature 99f°. The third day she ate chicken, 
and, when about to be removed to another bed, asked if she could not walk, 
said she felt all right. She gained strength rapidly, looked well, and left the 
hospital in a little over two weeks after the operation. 
October 5th patient reported that she was doing well. November 5tli, 1887, 
she dispensary record book says: Mrs. E. looks better and is still improving; 
says she “feels strong, able to do her work, aud has not felt so well for ten 
years.” She wrote April 21st, 1888 : “Three weeks after leaving the hospital 4 
ONES : COLPO-HYSTERECTOMY 
I resumed my avocation of washing and ironing, and now I feel I am a new- 
born creature.” December 13th, 1389, she wrote : “ I now feel first-rate, my 
appetite is good, and I am growing stronger from day to day ; I cannot feel 
too thankful that I am restored to health and brought back to my' family and 
children.” 
April, 1890 : Mrs. E. visited the dispensary; looks remarkably well, and sup- 
ports herself and family by washing and scrubbing. July 20th, 1891: Mrs. E. 
attends to her daily duties as janitress of a large bank building. September 
8tli, 1892 : Still has no return of the disease. 
Case III.—Mrs. H. came to Throop Avenue Dispensary July 22d, 1887; 49 
years old; married twenty-five years; had four children, the youngest child 19 
years of age ; says she has been sick since the birth of this child, but has suf- 
fered more especially within the last five years, and lately has had darting and 
shooting pains in the pelvis, a constant burning and distress, with a bearing 
down and an offensive watery discharge ; said she would rather die than endure 
the torment, and that she was not able to do her work nor to care for her hus- 
band and family. 
On examination the whole cervix was found to be in a condition of ulcera- 
tion, which a microscopical examination proved to be carcinomatous. Vaginal 
hysterectomy was performed at the Woman’s Hospital, October 28th, 1887. 
Peculiar difficulties attended this operation on account of an intermural myoma 
in the posterior wall of the fundus, and an extreme retroversion. The uterus 
was first placed in normal position and delivered anteriorly as in the previous 
case. An incision was made in the anterior part of the mucous membrane of 
the cervix as far from the ulcerating surface as possible, the extent of the 
bladder noted and its attachments with the vaginal tissue carefully separated 
from the cervix, and the peritoneal cavity opened anteriorly, the uterus 
brought out, and the left broad ligament secured at the upper portion with 
ligatures, the lowrer part clamped with forceps and separated; the uterus could 
thus be still further delivered. And in the same manner the right broad liga- 
ment was tied and clamped. 
Every day the wound was redressed, the old dressings removed and new 
ones put on. The patient did remarkably well. In two weeks she was able 
to sit up, and left the hospital on the 19th of November. On the 22d she 
came to my office; looked well. In December again reported herself as getting 
along excellently, and repeatedly expressed her thanks for what had been done 
for her in the hospital, as well as for the kind care and attention she had there 
received. June, 1892, five years after the operation, there is no return of the 
disease; the patient looks remarkably well and is in excellent health. 
Case IV.—Mrs. N. This case was presented with rather urgent symptoms— 
ulceration, bleeding, and offensive discharge—yet it was then regarded only 
as a deep transverse laceration of the cervix. There were more emaciation,, 
feebleness, and nervous depression than in either of the preceding cases. 
The patient was 35 years old; married ten years; had four children, the 
youngest being 4 years of age. She entered the hospital September, 1887. 
Microscopical examination showed the disease to be a round-celled sarcoma, 
apparently limited to the cervix. I decided to do amputation, hoping thereby 
to get rid of all the disease. This operation was performed September 17tli, 
1887, with thorough antiseptic precautions. The disease soon reappeared ; it 
proved to be extremely malignant, progressed rapidly. The only chance of 
saving the patient was by the immediate and entire extirpation of the organ. FOR MALIGNANT DISEASE. 
5 
The husband was fully informed of her condition; was anxious that the opera- 
tion should he performed, and as soon as possible. In the meantime every- 
thing was being done to improve the patient locally, and to build up as much 
as possible her general health and strength. On the first day of October, 1887, 
I removed the uterus. The patient was so exceedingly feeble that at times it 
was difficult for the physician who administered the ether to perceive that she 
was breathing. The cervix was brought down with a double tenaculum ; the 
position of the bladder was carefully noted, and was found to extend quite to 
the point of the ulceration. I curetted the cervix, thoroughly disinfected, 
packed with small bits of cotton wet in 1 ; 5000 bichloride solution, then 
carefully dissected away the bladder and vaginal tissues, opening the peritoneal 
cavity anteriorly. The mucous membrane of the vagina and the peritoneum 
were stitched together, so as to protect the bladder, and the loop of the thread 
conveniently served to hold away the edge of the wound and the peritoneum. 
The fundus was next seized with Volkmann's forceps and brought out ante- 
riorly. Sponges with strings attached were passed into the peritoneal cavity 
to protect and keep back the intestines. The broad ligament on the left side 
was ligated at the top, and the lower portion secured by forceps, then sepa- 
rated at some little distance from the uterus, and as much as possible of the 
perimetric tissue was removed and the pedicle cauterized. The right broad 
ligament was treated in the same manner, after which the posterior attachments 
of the uterus were readily separated and the organ delivered. The mucous 
and peritoneal membranes were held together by pressure forceps, the sponges 
removed, the parts cleansed, and the vagina packed with iodoform gauze. 
The operation lasted about thirty-three minutes, though the immediate work of 
opening the peritoneal cavity and removing the uterus was done in less than 
thirteen minutes. When the operation was completed the patient seemed more 
comfortable than before it commenced, and she was very much better and 
stronger than after the preceding operation. She was placed in bed with bot- 
tles of hot water around her, and was apparently doing well, except the pulse 
was extremely feeble and very rapid. 
The next morning the patient’s pulse was still extremely feeble and very 
rapid, but there was no increase of temperature. I put on new dressings ; pa- 
tient began to grow better, passed urine normally, and had a natural evacua- 
tion of her bowels. 
October 4th she was moved into another ward; October 20th was able to be 
out of bed; October 24th up all day, helping to look after another patient; 
and October 28th was removed to the children’s department of the hospital for 
convalescence. 
It will be noted that the patient recovered more rapidly and was stronger 
after the hysterectomy than after the cervix operation. October 30th she 
came to my office complaining of pains through the bladder, visited me fre- 
quently, and, because of so much suffering in her bladder, I feared there would 
soon be a reappearance of the disease. Temporarily I administered tonics. In 
this case the disease seemed so malignant that I presumed there would be a 
recurrence. I could only hope the operation would prolong her life for a few 
months. The patient was now lost sight of. I heard nothing from her and con- 
cluded that there had been a reappearance of the disease and that she was prob- 
ably not living. Still, in June, 1891, I determined to find her, if possible, or 
learn her subsequent history. Finally I ascertained her residence, and walked 
in as she and her little family were sitting down to their Sunday midday meal. 6 
JONES : COLPO-HYSTERECTOMY 
She was the picture of health, blooming and apparently ten years younger 
than when I had last seen her. She and her husband both expressed great grati- 
fication that she had had the operation and that her life was saved. August, 
1892, nearly five years after the operation, the patient is still in good health. 
Case Y.—Mrs. L. E. called at Tliroop Avenue Dispensary October 21st, 1887; 
feeble, pale, emaciated, cadaverous, and had the appearance of one in the last 
stages of consumption; seemed hardly able to walk. She was 34 years old ; 
married eleven years ; had five children, youngest 2 years old. She complained 
of pain in the back and shooting and darting pains in the lower part of the 
pelvis, and had a constant watery discharge streaked with blood and very 
offensive. She had no appetite, was sick and not able to do any kind of work 
or to care for her family. 
Examination showed ulceration at the seat of an old and extensive laceration 
of the cervix. The whole surface was bathed in pus and blood. October 23d 
she called again at the dispensary, complaining of the same prostration and 
feebleness, and watery, profuse discharges. Again she asked to go to the hos- 
pital. She was admitted on the 26th of October, still very feeble. Antiseptic 
douches were used and the womb treated every day, yet the offensive watery 
discharge continued. As soon as she could gain a little strength the cervix 
and vagina were thoroughly cleansed by brush, soap and water, and after- 
ward by bichloride solution. The uterus was douched internally by an anti- 
septic solution ; it was then curetted, and an effort was made to restore the 
deep transverse laceration. All the diseased tissue, so far as I could judge 
at the time, was removed, and the cervix closed with four stitches on each side. 
The patient continued extremely feeble; no special rise in temperature or pulse, 
still for days after she looked like one nearly dead, scarcely able to lift her 
head from the pillow. Antiseptic douches were given every day, yet at the end 
of a week the whole field of operation was a mass of suppuration; every stitch 
had ulcerated out. Microscopical examination proved the disease to be carci- 
noma. It was apparently extending to the fundus, and I feared had even in- 
volved other structures. I informed the husband of the nature of the disease; 
that nothing would save her but entire extirpation of the uterus, and even that 
gave but a chance of saving her life. The husband expressed in writing his 
wish for the operation, and, as soon as the patient was able, arrangements were 
made for its performance. On the 28tli of November she was again lifted 
from her bed, again carried in the nurse’s arms to the operating table, and 
hysterectomy was performed with the greatest celerity. First the ulcerating 
tissue was curetted and the cervix packed with bits of cotton. Next the 
extent of the bladder was carefully noted, and an incision was made through 
the vaginal membrane and as far from the ulceration as possible; the bladder 
and vaginal tissue were separated, keeping close to the uterus, and the peri- 
toneal cavity was opened into anteriorly, clamping the broad ligaments, and so 
removing the whole uterus in less than fifteen minutes. 
But for this special procedure, which not only gives more expedition but 
causes less shock, I do not believe the patient could have survived the operation. 
After it was over she was extremely feeble and exhausted. She was carefully 
removed to the bed, well covered, and bottles of hot water were placed around 
her. The pulse was still very rapid. When the wound was redressed she 
seemed more comfortable, passed urine normally, and at once began to show 
more strength and better condition ; had some appetite, and improved beyond 
all expectation. Referring to this case in the New York Medical Journal, EOK MALIGNANT DISEASE. 
7 
September 1st, 1888, I said : “ The patient was able to be up in two and a half 
weeks after the operation, stronger than she had been for months ; left the 
hospital December 23d, and since has been able to resume the charge of her 
large family.” February, 1888, dispensary record: “Mrs. E. looks well, is 
stronger, and still improving.” 
After this I did not see this patient or hear from her till April 28th, 1890. 
At this time she looked remarkably well, better than one could have supposed 
possible. Besides the care of her family she attended to her small grocery 
store. When she lay in the hospital before the operation she was like one 
almost dead, pale, wan, and feeble, the sickly discharge apparently draining 
her life away ; now her eyes were bright, the sunken, hollow cheeks were tilled 
out, and the color came and went. My work for her in the hospital, then ap- 
parently without hope, had resulted in good, because the operation was fortu- 
nately done before the rapidly growing disease had infected the neighboring 
vital structures. The delay of a few months or weeks might have been fatal. 
These few cases prove beyond doubt that by a timely ope- 
ration malignant disease may be eradicated from the system. 
Certainly years were added to the life of each of these wo- 
men ; to each one much suffering was saved and a sure death 
averted. Dr. (t. F. Shrady, in his article on the “ Curability of 
Cancer by Operation,” says: “ Cancer is essentially a local dis- 
ease. It begins as an isolated growth in a particular tissue, and 
progresses by proliferating into neighboring parts, and can be 
cured by an operation.” 1 This is a most important fact, and 
upon it rests the whole justifiability of the operation of colpo- 
hysterectomy. This fact, at the same time, makes it the duty 
of a surgeon to remove, when possible, a malignant, growth in 
whatever part of the body found and as soon as discovered. 
Virchow says: “If cancer in its beginning, and often very 
long afterward, is a local disease, it must be possible during 
this period locally to cure it.”2 
Billroth, De Morgen, and others sustain the same idea. 
Erichsen3 says: “ It cannot be doubted that in some cases a 
cancerous tumor may be removed with every expectation of the 
patient being completely freed from the disease.” Macewen4 
says: “ The opinion that it is a constitutional disease is pro- 
ductive of the most dire results,” adding: “I ask all who 
agree with me that carcinoma is, at an early period, both a local 
and a curable disease, to do everything in their power to con- 
vince others to that effect, and to try and prevail on all those 
1 Medical Record, January 22d, 1887. 
2 Virchow's Archiv. 
3 Erichsen's “ Science and Art of Surgery,” p. 1002, vol. i., eighth edition. 
4 Glasgow Medical Journal, 1886, pp. 287, 291. 8 
JONES : COLPO-HYSTERECTOMY 
who suffer from this affection to submit themselves to an ope- 
ration at the very earliest moment.” Butlin1 says: u I have 
no doubt of the power of surgery to cure a certain number of 
cancerous patients. There need be no hesitation in claiming 
that all persons who remain well and free from cancerous dis- 
ease for three years after the operation have been cured of the 
disease.” 
Dr. John Williams5' considered a case cured if two years have 
relapsed without recurrence. John Marshall,3 F.R.S., of Lon- 
don, says: “ I could point to persons living, and now perfectly 
well, eight, nine, ten, eleven.and twelve years since operation.” 
Mr. Edgerton Jenkins4 said lie had notes of cases of cancer in 
which, after a lapse of five years, in one case thirteen, there 
had been no return of the disease. A'elpeau states that he has 
perfectly cured patients by the removal of cancerous tumors— 
at least that no return has taken place for twelve, fifteen, or 
twenty years after extirpation. 
In 1846 Brodie stated that fourteen years previously he re- 
moved a breast affected with scirrhous tumor, and the lady was 
still in good health; and one patient, on whom he performed the 
operation thirteen years before, continued free from the dis- 
ease. Ferguson6 says: “ As excision gives the only chance of 
security, an operation should always be resorted to, provided the 
knife can be carried beyond the supposed limits of the disease; 
and, moreover, I deem it one of the duties of the practitioner to 
urge the patient to submit to such a proceeding.” 
Dr. G. F. Shrady,8 in the above-mentioned article, says fur- 
ther: “Statistics might be multiplied to prove the chances of 
radical cure in cases which have been treated by the knife, and 
of the certainty of prolonging life by excision of cancerous 
growths. One case was alive and well nineteen years after an 
operation, another dying of apoplexy eleven years and three 
months after .; one, operated on by Dr. Frank H. Hamilton, sur- 
vived twenty years, another was living ten years after the extir- 
1 “ Operative Surgery for Malignant Disease.” By H. C. Butlin, Professor 
of Pathology in the Royal College of Surgeons, London. 
2 “ Harveian Lectures on Cancer of the Uterus.” 
* “ Morton Lectures on Cancerous Diseases,” British Medical Journal, No- 
vember 23d, 1889, p. 1145. 
4 British Medical Journal. 
5Erichseu’s “ Science and Art of Surgery,” p. 1003, vol. i. 
6 Medical Record, January 7th, 1887. FOR MALIGNANT DISEASE. 
9 
pation of a cancerous breast; one by Dr. C. Deadrick, of Knox- 
ville, Tenn., survived eight years, and died of another disease.” 
July 10th, 1877, I removed a scirrhous cancer the size of a 
lemon from the breast of a woman 39 years of age. Ether was 
administered by Dr. Lewis Pilcher. At one stage of the opera- 
tion he suggested that the whole breast be amputated, which 
indeed was excellent advice; but I was anxious to save the or- 
gan, as I had promised the patient to do so if possible. 1 felt 
certain that 1 was cutting into healthy tissue, and that all the 
malignant disease would be removed. With the tumor I took 
away a considerable portion of the surrounding structure. This 
was the safety of the patient. She made a rapid recovery, and 
when last heard from, nearly twenty years after the operation, 
was still well and had no recurrence. 
I did an operation for removing a similar malignant growth, 
and of about the same size, from the breast of a woman a few 
years younger. Ether was administered by Dr. Charles Corey. 
Now nearly twenty years have elapsed, and there is yet no 
return of the disease. Another patient, Mrs. T., stronger and 
more vigorous than either of the two preceding, had in her 
breast a smaller and apparently less malignant tumor, causing 
no trouble in any way, and she, thinking it quite innocent, gave 
it no attention. Finally she was brought to me by a friend of 
hers. This was in 1888. The little, movable, clierry-sized ball 
had become fixed, ulceration had commenced, and her whole sys- 
tem was more or less infected. I could only tell the patient that 
by the removal of the growth, and as much as possible of the 
surrounding tissue, the progress of the disease might be stayed, 
which, advancing as rapidly as it now seemed to be, would 
inevitably in a short time prove fatal. I removed the whole 
mammary gland and all the glands in the axilla, making the ope- 
ration most thorough. In about a year the disease reappeared ; 
I again removed the growth, with a liberal amount of the ad- 
joining tissue and all of the newly enlarged glands—cleaned out 
the whole axillary space. The cancer soon reappeared, and 
when I, at her request, was preparing for a third operation, the 
patient was persuaded by some one to go to the Seney Hospital. 
There the operation was performed by Dr. Lewis Pilcher, and, 
as I understood, though he removed the rapidly appearing 
growth at short intervals, still at the end of a few months the 
patient died in great sulfering. 10 
JONES : COLPO-HYSTERECTOMY 
If in this instance the tumor, when it was a little movable 
ball, had been removed with the tissue in immediate proximity, 
the patient would probably have had no further trouble, and 
even the fact of its malignancy might have been questioned. It 
was then a local disease, had in no way infected the system, and 
could at that time, I believe, have been entirely eradicated. At 
that period, too, the operation would have been exceedingly 
simple; and, according to the teachings of Butlin, who has had 
vast experience in St. Bartholomew’s Hospital, London, there 
would then have been no necessity to have removed the whole 
mammary gland, any more than, in an advanced stage of disease 
of one breast, to remove both. Soon after the inflammatory 
infiltration commenced, and the cancer epithelia were being car- 
ried by the lymphatics to distant parts of the body, and it was 
no longer a local disease. 
Does not vaginal hysterectomy prove that cancer is curable f 
Though a comparatively recent operation, and though it has 
often been performed under the most inauspicious circum- 
stances, yet there are many instances reported where, by this 
operation, malignant disease has been wholly removed and the 
individual apparently restored to health. Langenbeck’s histo- 
rical case—one of the first vaginal hysterectomies performed— 
lived free from the disease for twenty-six years after. Thomas 
Keith1 removed a uterus in 1881, and nine years after the ope- 
ration there was no return of the disease and the patient was in 
good health. 
N. L. Brewis2 says: “In May, 1881, Dr. McDonald removed 
a large, sloughing, cauliflower excrescence from a patient aged 
36, and to this day she remains well and free from return.” 
Olshausen tells of two that had no return at the end of eight 
years, and one at the end of nine years. ' In his statistics of 
“ five hundred and twelve cases of carcinoma in 1885 in Ber- 
lin,” he states that “one hundred and sixty-three underwent the 
radical operation; nearly half were free from relapse two 
years after.” This, in most cases, means a cure. Schauta showed 
that forty-seven per cent of his cases had no return at the end 
of two years. Tannen3 reported the statistics of the Breslau 
1 British Medical Journal, January 10th, 1891, p. 58. 
2 Edinburgh Medical Journal, 1891, vol. ii., p. 1002. 
3 Arcliiv fur Gyniikologie, Bd. xxxv., Heft 3. Quoted by H. C. Coe in 
American Journal of the Medical Sciences. FOR MALIGNANT DISEASE. 
11 
clinic from June, 1S83, to November, 1889: “One hundred and 
three cases of vaginal hysterectomy—47.4 per cent of the pa- 
tients were free from the recurrence at the end of three years 
several reported as well six years after the operation.” 
John Williams 1 says, in speaking of his statistics, that twenty- 
eight per cent of all operations are cured. Of thirty-one of 
Leopold’s cases at Dresden, no fewer than seventeen, or fifty 
four per cent, presented no signs of recurrence at the end of 
three years. Leopold, Schroder, Fritsch, and Martin : Out of 
two hundred and fourteen, at the end of one year thirty-five 
were living; at the end of two years, twenty-five; and at the 
end of three, twenty. Thus twenty at least were cured per- 
manently who without the operation were doomed to certain 
death. 
Billroth, Esmarch, Fischer, Yolkmann : Out of six hundred 
and forty-three cases, sixty-five were well at the end of two 
years. Martin 2 says, in his late work, out of sixty-six, eleven 
died under the influence of the operation, thirty-one have re- 
mained free from recurrence of the disease ; this gives, there- 
fore, as a result, seventy per cent of cures. Pozzi believes forty 
or fifty per cent are cured. 
Prof. Lane,3 of San Francisco, who was the first to perform 
the operation of vaginal hysterectomy in the United States (No- 
vember, 1878), said, September, 1888: “I have operated four- 
teen times, with one death in forty-eight hours; all the rest are 
yet living and evidently cured.” 
Fritsch4 reports sixty cases from his clinic at Breslau, and 
says: “ Nine were well at the end of two years, while the re- 
mainder were without a return after the first six months,” which 
he considers the most dangerous period. Terrier 6 tells of two- 
who survived for three years, one for nearly five years, one over 
six. The following shows statistics of the number who were 
well at the end of two years : “ Billroth, one hundred and forty- 
five cases—twenty-eight, or 5.5 per cent. Esmarch, two hun- 
dred and twenty-five cases—ten, or 11.5 per cent. Fischer, 
1 Transactions of the London Obstetrical Society, 1890. 
3 “ Pathology and Therapeutics of the Diseases of Women.” By A. Martin. 
Translated by Ernest W. Cushing. Second edition, p. 310. 
Gynecological Transactions, 1888, p. 207. 
4 Centralblatt fur Chirurgie, June 18th, 1887. 
6 Revue Medico-Chirurgical des Mals des Femmes, December, 1891. 12 
JONES : COLPO-HYSTERECTOMY 
one hundred and forty-seven eases—twenty, or 8.3 per cent. 
Volkrnann, one hundred and thirty-one eases—seven, or sixteen 
per cent. Krister, one hundred and thirty-two cases—fourteen, 
or sixteen per cent; and Martin,1 sixty-six cases—nine, or sixty 
per cent.” Thus by timely operation eighty-eiglit were saved 
of those who were otherwise certainly doomed. 
The conclusion thus forces itself upon us that by a timely 
operation one may be cured of this most painf ul and, perilous 
disease, as F. H. Martin,2 of Chicago, says: “ It seems to me 
that vaginal hysterectomy is the means of the saving of many 
women from one of the most horrible deaths of which it is pos- 
sible to conceive.” 
Early Mortality.—At first, even with the best operators, there 
was a large mortality as the immediate result of the operation. 
It was the most helpless cases that came. There could be no 
selection. The difficulties were great. It was going into un- 
seen dangers to save hopelessly shipwrecked sufferers. The 
grave alternative was : Save, or more heavily weight them that 
they sink even more rapidly! The responsibility was tremen- 
dous. Brave, noble, and heroic were these surgeons who thus 
endeavored to rescue the lost and perishing. It was a marvel 
that any were saved. 
The immediate results of the operation are seen in the fol- 
lowing statistics: 3 
In 1881 Olshausen collected 41 cases with 29 per cent mortality. 
In 1883 Sanger “ 153 “ “ 28 
In 1884 Engstrom “ 157 “ “ 29 “ 
In 1886 Hegar “ 257 “ “ 23 
Immediate mortality up to the end of 1886 : Fritsch, 60 cases, 7 deaths ; Leo- 
pold, 42 cases, 4 deaths; Olshausen, 47 cases, 12 deaths ; Schroder, 74 cases, 
12 deaths; Staude, 22 cases, 1 death; Martin,4 66 cases, 11 deaths ; and 
Brennecke, 13 cases and no deaths. 
Dr. Wm. Duncan5 reported to the London Obstetrical Society, January 
14th, 1885, two cases of total extirpation of the uterus, one death. He pre- 
sented all the statistics he could find recorded up to that date, giving 276 in 
number, 79 deaths—a total mortality of 28.6 per cent. 
1 Annals of Gynecology. 
2 Journal of American Medical Association, 1890, p. 575. 
* Annals of Gynecology. 
4 Ibid. 
5 Transactions of London Obstetrical Society, January, 1885. 13 
FOR MALIGNANT DISEASE. 
No. of 
Operations. 
Deaths. 
No. of 
Operations. 
Deaths. 
Ahlfeld 
2 
1 
Freund 
2 
1 
G. Bantock 
1 
1 
Hahn 
7 
2 
Bardenheur .. 
1 
1 
Helferich 
1 
Baum 
4 
2 
Malins 
f 
i 
Bernay 
1 
Netzel 
1 
1 
Billroth 
12 
4 
Ogston 
2 
1 
Bockel 
1 
25 
7 
Bolling 
1 
Silnger 
2 
1 
Bompiani 
1 
i 
Schalz 
10 
3 
Bottini 
3 
Scliede 
2 
2 
Brunner 
10 
3 
Schroder 
27 
8 
Calderini 
1 
1 
Simpson, A. R.. 
1 
1 
Caselli 
1 
1 
Tauffer 
5 
1 
Czerny 
11 
3 
Teuffel 
7 
3 
Demons 
4 
2 
Thiersch 
6 
1 
Duden 
2 
1 
Thornton 
1 
1 
Edis, A. W. . 
1 
1 
Williams, John. 
3 
2 
Engstrom, 0. . 
2 
1 
Zweifel 
3 
1 
Esmarch 
2 
1 
RESULTS OF INDIVIDUAL OPERATORS—STATISTICS OP W. DUNCAN. 
Dr. Sarah Post1 collected over 700 performed before the end of 1887, with the 
total death rate of 24 per cent. At a meeting of the Surgical Society of Paris, 
Terrier2 reported 34 operations with an immediate mortality of 25 per cent. 
Maurice Hache3 gives 495 operations in which the mortality was 24.29 per 
cent: 
Before 1883 
164 hysterectomies for cancer 
43 deaths.. 
26.21# 
In 1883 
79 hysterectomies for cancer 
18 deaths.. 
22.28# 
In 1884 
107 hysterectomies for cancer 
27 deaths.. 
25.23# 
In 1885 
69 hysterectomies for cancer 
14 deaths.. 
20.28# 
4 hysterectomies for other causes 
1 death.. 
In 18*6 
59 hysterectomies for other causes 
15 deaths.. 
25.42# 
7 hysterectomies for other causes 
1 death.. 
Deaths. 
Cases. 
Deaths. 
Cases. 
Baum 
2 
5 
M tiller 
4 
Billroth 
4 
12 
Bottini 
5 
Teuffel 
3 
5 
17 
Czerny....... 
3 
8 
Martin 
18 
85 
Hahn 
1 
5 
Fritsch 
2 
23 
Thiersch 
1 
4 
Pean 
3 
5 
Schatz 
3 
10 
Brenuecke... . 
21 
Schroder 
9 
34 
Novaro 
io 
20 
Tauffer 
1 
5 
Buttlehner 
l 
9 
Olsliausen 
.7 
32 
Terrier 
2 
10 
Demons 
2 
5 
Bonilly 
3 
11 
Duvelius 
1 
8 
Trelat" 
1 
4 
Total, 81 
deaths in 358 operations, or 22.62^. 
TIIE FOLLOWING STATISTICS OP INDIVIDUAL OPERATORS. 
1 “ Colpo-hysterectomy for Cancer,’’ American Journal of Medical Sciences, 
January, 1886. 
2 Revue Medico-chirurgical des Mals des Femmes, December, 1891. 
3 Revue des Sciences de Med., Paris, xxix., pp. 721-739. 14 
JONES I COLPO-HYSTERECTOMY 
Dr. A. P. Dudley gives in his tables the following statistics of individual 
operators and the results :1 
Operator. 
Opera- 
tions. 
Date. 
Result. 
Dr. Anderson. San Fran- 
1 
Oct., 1881 .. 
Recovery with a vesical fistula. 
cisco. 
Dr. W. IT. Baker, Boston.. 
1 
March, 1885. 
Recovery. 
Dr. A. C. Bernays, St. Louis 
6 
1883 to 1885. 
Recovery. 
Dr. J. C. Blake, Boston 
1 
Jan., 1885... 
One death in twelve hours from 
shock. 
Dr. W. T. Bull, New York. 
5 
1883 to 1886 
One death. 
Dr. Burke, Connecticut .. 
1 
Nov., 1882 
Recovery rapid. 
Dr. Cushing, San Francisco 
1 
Sept. 4, 1881 
Recovery rapid. 
Dr. B. F. Dawson, N. Y. 
1 
April, 1885.. 
Death on third day from fever. 
Dr. D. Vecchi, San Fran- 
2 
March, 1883. 
Recovery. 
cisco. 
Dr. A. Palmer Dudley, 
New York. 
2 
Dec., 1883, to 
1886. 
One death thirty-nine hours 
from acute nephritis. 
Dr. E. C. Dudley, Chicago. 
1 
May 23, 1882 
Died in four hours from shock. 
Dr. J. W. Elliot, Boston... 
1 
May, lb85 .. 
Death on fifth day from hemor- 
rhage. 
Dr. P. F. Eve 
1 
Apr. 16, ’50. 
Recovery. 
Dr. C. Fenger, Chicago.... 
1 
Sept. 19, ’81. 
Recovery rapid. 
Dr. M. Franklin, Philadel- 
1 
Nov. 11, ’82. 
Death on fifth day from shock. 
phia. 
Death caused by septicemia. 
Dr. Goodell. Philadelphia.. 
1 
Nov. 11, ’82. 
Dr. It. J. Hall, New York.. 
1 
Aug,, 1886.. 
Recovery. 
Dr. J. B. Hunter, New 
York. 
1 
Oct. 24, 1885 
Death same evening from 
shock. 
Dr. E J. Ill, Newark, N. J. 
1 
May 30, 1885 
Recovery. 
Dr. J. Taber Johnson, 
Washington. 
1 
June, 1885 . 
Death in four hours from peri- 
tonitis. 
Dr. F. Lange, New York.. 
1 
Nov. 11, ’86. 
Recovery rapid. 
Dr. L. C. Lane, San Fran- 
9 
1878-1886... 
Three deaths. 
cisco. 
Dr. W. H. May, Stockton, 
1 
Sept., 1882.. 
Death on fifth day. 
Cal. 
Dr. Paul F. Munde, N. Y.. 
3 
1883 to 1885. 
Two deaths.2 
Dr. Polk, New York 
6 
Julv,1884, to 
1886 
Two deaths. 
Dr. Beamy, Cincinnati 
2 
1886 
One death in forty-eight hours 
from shock. 
Dr. W. E. Taylor, San 
2 
Aug., 1881.. 
Recovery rapid. 
Francisco. 
Dr. Thomas, New York 
1 
Oct., 1882... 
Died on seventh day from sep- 
ticemia. 
Dr. Yon Ramdohr, N. Y... 
Dr. Von Hoffmann, San 
Francisco. 
1 
July, 1886 .. 
Aug., 1883, 
to 1884. 
Recovery. 
Recovery. 
Dr. It. F. Weir, New York. 
2 
Nov., 1884, 
to 1885. 
One death from shock and loss 
of blood. 
Dr. Wile, Danbury, Conn... 
1 
Nov., 1883.. 
Died third day from shock. 
Dr. C. M. Wilson, Philadel- 
1 
1886 
Recovery. 
phia. 
1 New York Medical Journal, “Vaginal Hysterectomy in America,” July 
9th, 1887. 
2 In the New York Medical Journal of July 80th, 1887, Dr. Munde says: 
“ I desire to add to this number two cases which I operated on February 2d 
and 23d, 1887, with recovery; also a third which has thus far progressed so 
favorably that I have no reason to doubt the patient will recover.” FOR MALIGNANT DISEASE. 
15 
The following is from a table of J. F. Binnie, Kansas City : 
No. of 
Operations. 
Deaths. 
No. of 
Operations. 
Deaths. 
Baer 
2 
1 
Kaltenbacli ... 
80 
2 
Bernays 
22 
2 
Leopold 
83 
5 
Bokelman 
19 
2 
Munchmeyer .. 
80 
4 
Breunecke... . 
21 
0 
Slawjanski .... 
80 
9 
20 
1 
Tannen 
103 
10 
Carson 
Eastman 
4 
13 
2 
3 
Gill Wylie 
20 
1 
Dr. John Scott1 says : “ In 1889 the immediate mortality in San Francisco 
was twenty to twenty-five per cent.” 
F. H. Martin, of Chicago, gives, January 31st, 1891, the following statistics 
of individual operators: 
No. of 
Operations. 
Deaths. 
No. of 
Operations. 
Deaths. 
Boldt 
15 
1 
M. D. Mann.... 
4 
1 
Bull 
6 
1 
Piukliam, J. S.. 
4 
0 
Byford 
20 
1 
' Reamy2 
12 
2 
II. C. Coe .. 
8 
3 
H. C. Coe, and 
E. C. Dudley... 
G 
1 
Jas. B. Hunter8 
19 
6 
S. E. Gordon... 
3 
1 
Baclie Emmet.. 
4 
1 
R. B. Hall 
1 
1 
Etheridge4.... 
4 
1 
J. Taber John- 
E. W. Mont- 
son 
5 
3 
gomery 
3 
1 
E. E. Montgom- 
W. M. Polk5... 
22 
5 
ery 
5 
1 
Pean. 1886-1887 
22 
7 
H. O. Marcy— 
4 
2 
Edebohls6 
5 
1 
F. H. Martin... 
5 
0 
The above statistics sliow as the immediate results of the 
operation a mortality of over twenty per cent. But we find 
just as great mortality in the removal of malignant disease 
from other parts of the body. Butlin 7 gives the following 
statistics of operation on other parts of the body for cancer: 
1 Gynecological Transactions, 1884, p. 230. 
2 Journal of the American Medical Association, Chicago, 1891, vol. xvi. 
p. 152. 
* American Journal of Obstetrics, July, 1890. 
4 Journal of the American Medical Association, December, 1887. 
5 American Journal of Obstetrics, 1891, p. 878. 
6 American Journal of Obstetrics, 1891, p. 881. 
1 “Operative Surgery for Malignant Disease.” By H. C. Butlin, Professor 
of Pathology in the Royal College of Surgeons. 16 
JONES : COLPO-HYSTERECTOMY 
“Sixty-five cases of complete extirpation of the larynx for 
carcinoma, with thirty deaths due to the operation, and only 
one patient alive and well more than two j-ears after. Six 
cases of esophagectomy, with three deaths; of the three pa- 
tients who survived the operation, two were known to have died 
of recurrence of the disease, and the third was lost sight of. 
Forty patients from whom malignant tumors of the kidney were 
removed, with twenty-eight deaths. Of the recoveries only one 
was permanent, the others having been followed speedily by the 
recurrence of the disease (Gross). One hundred and forty-eight 
cases of removal of the uterus through the abdominal incision, 
with one hundred and six deaths; and Gusserow says ‘that all 
the patients whose histories have been followed up suffered from 
recurrence of the disease.’ Fifty removals of cancerous thyroid, 
with thirty deaths ; of those who recovered from the operation, 
only two survived more than a year. Fifty-five patients from 
whom cancer of the pylorus was recovered, of whom forty-one 
died from the operation, and not one is known to have made a 
permanent recovery. 
Here,” says Butlin, “ are the records of surgical operations 
on six parts of the body, the total number of cases three hun- 
dred and sixty-four, with one hundred and twenty-six recoveries, 
two hundred and thirty-eight deaths due to operation ! And 
only two alive and well at the end of two years!” Still, Butlin 
wisely observes: “ The two hundred and thirty-eight persons 
who perished of the operations were in any way doomed to 
death within a short period, and so large a mortality is more 
than justified by the cure of one hundred and twenty-six persons 
who would have died but for the operation.” 
Only by an operation could these be saved, and the object 
should be to save as many as possible. J. C. Cullingworth,1 of 
St. Thomas’ Hospital, London, says : “ If every newly performed 
operation that shows at first a high death rate is to be at once 
denounced as unjustifiable, there is an end to surgical enterprise 
and surgical progress.” 
Later Statistics.—The immediate mortality in colpo-hyste- 
rectomy for cancer continues to diminish. In 1886 A. Martin 
gave the statistics of vaginal hysterectomy as three hundred and 
1 Transactions of the London Obstetrical Society, 1890, vol. xxxii , p 
160. 17 
eleven cases with forty-seven deaths, that is, 15.1 per cent; at the 
same time the death rate for breast amputation was 15.6 per cent. 
When Tannen reported the work of the Breslau Clinic the mor- 
tality in the first sixty cases was 11.6 per cent; in the last forty- 
three cases 6.9 percent. Thus statistics everywhere are show- 
ing continually a better per cent; and with increased knowledge 
of the operation, and opportunities of judging of the condition 
of patients, there will be increasingly better results. When Dr. 
Wm. Duncan presented his paper on “Total Extirpation of the 
Entire Uterus ” to the London Obstetrical Society, January 14th, 
1885, reporting two cases, one death in twelve hours, every 
speaker who took part in the discussion agreed with Dr. Dun- 
can in condemning the operation as unjustifiable, except two, 
Sir Spencer Wells and Dr. Graily ILewitt. At the close of 
the discussion Dr. Duncan1 expressed himself as feeling sure 
that further experience would never bring the mortality down 
from 28.6 per cent to that which follows supravaginal amputa- 
tion, 7.5 per cent. 
This assertion is being every day disproved by the recent work 
of many operators. Joseph Price2 reported fifty-four cases, with 
one death; Gill Wylie, thirty-one cases, with one death; II. J. 
Boldt,3 forty-four cases, with three deaths; F. Krug,4 fifteen ope- 
rations done from June, 1888, to March 9th, 1889, with one death; 
E. W. Cushing,5 thirty-eight cases, with one death of those under 
his immediate care; Charles A. L. Reed,6 Cincinnati, eleven 
cases, witli one death ; Dr. T. A. Beamy,7 nine cases, with one 
death. Probably in the next fifty of each of these operators there 
will be no deaths. 
J. Sinclair,8 Manchester, England, in his last twenty-one cases 
had only onedeath ; James Braithwaite, in twelve cases, one death. 
In 1889 Kaltenbach reported sixty-two cases of total extirpation 
for malignant disease. 
1 Transactions of Obstetrical Society of London, January, 1835. 
2 Annals of Gynecology and Surgery, June, 1892. 
3American Journal op Obstetrics, October, 1892, p. 540, “Vaginal 
Hysterectomy for Cancer of the Uterus.” 
4 American Journal op Obstetrics, 1891. 
5 Annals of Gynecology and Surgery, June, 1892. 
6 Transactions of American Association of Obstetricians and Gynecologists, 
1890. 
1 Gynecological Transactions, 1888, p. 205. 
f British Medical Journal, November 8th, 1890, p. 1065. 18 
JONES : COLPO-HYSTERECTOMY 
of the uterus, with two deaths; Leopold, one hundred and ten 
cases, with six deaths ; Schauta reported sixty-five cases, with five 
deaths ; Fritsch, sixty cases, with an immediate mortality of seven ; 
Miinchmyer, eighty operations, with four deaths. At the Third 
Congress of the German Gynecological Society, held in Freiburg 
in June, 1889, Miinchmyer 1 reported that, in one hundred and 
sixty cases of total extirpation of the uterus performed at Dres- 
den between the years 1883 and 1889, the total mortality was 5.4 
per cent. Of the one hundred and twelve operations, fifty-two 
were performed in succession without a single death ; in eighty, 
only four of the patients died from the effects of the operation. 
Greig Smith2 says: “Brennecke has had eighteen cases and. 
Staude sixteen, all successful; Fritsch lost seven out of sixty, 
Martin eleven out of sixty-eight; Bull, of New York, five cases, 
one death. It .will therefore be seen that in skilful hands the 
operation is far from being unjustifiable on account of its mor- 
tality.” 
Thus hysterectomy for cancer may become a comparatively 
safe operation, and by it the patients may be entirely cured of 
cancerous or malignant disease. The practical question now pre- 
sents itself : Can malignant disease be as successfully removed 
by high amputation as by entire extirpation f 
If we could be certain that the malignant growth was confined 
to the cervix, then high amputation might be considered ; but 
by what knowledge or insight can we know this ? How can the 
surgeon possibly tell that the disease is limited to the cervix 
and has not extended beyond ? Is there any way for him to find 
this out ? Even if, to the naked-eye appearances, the disease is 
limited to the cervix, there may still be independent nodules and 
cancer nests in the fundus ; when apparently only a part of the 
cervix is affected, profound disease may be in other portions of 
the uterus. This has been repeatedly seen and emphasized by 
great surgeons both in this country and in Europe. Many in- 
stances are recorded where the disease in the cervix was com- 
paratively slight, and even surrounded with healthy tissue, yet 
in the fundus there were malignant formations even' more ad 
vanced and more serious. So when cancerous disease is found 
1 Transactions Obstetrical Society of London, 1890, p. 159. 
2 “ Abdominal Surgery,” second edition, p. 209. FOR MALIGNANT DISEASE. 
19 
in any part of the uterus the only safe procedure is to remove the 
whole organ. H. J. Boldt1 says : “ The entire uterus should be 
removed, even if seemingly the disease is only in its beginning 
at the portio or cervix.” Cushing:2 “It is not possible to 
decide how far up in the uterus the disease has extended.” 
Thomas Keith :3 “ I never hesitate between the partial and 
complete removal; for all we know, there may be cancerous 
nests in the very fundus, even though the disease may seem to 
the eye quite local and limited.” N. T. Brewis:4 “I would 
always advocate hysterectomy in preference to partial removal, 
for in removing the cervix alone we may leave behind an in- 
fected body.” Krug:6 “It is absolutely impossible to determine 
the extent of the disease before or even during this operation. I 
do not think we are allowed to do so imperfect and unreliable an 
operation as high amputation.” E. E. Montgomery 6 says : “We 
cannot, however, but coincide with the opinion of Brennecke that 
when any portion of the uterus is the seat of cancer, however 
slight, extirpation of the whole uterus is indicated.” Reed 7 
says: “If careful pathologists find it extremely difficult to make 
out the marginal lines by means of powerful lenses in the leisure 
of the laboratory, how impossible for the naked eye in theneces- 
sary hurry of the operating room!” George M. Gould 8 says: 
“Carcinomatous nodules have been found in the body of the 
uterus when apparently the cervix was infected with but the very 
earliest stages of the disease.” Ilichelot9 repeats the fact that 
when the disease was apparently limited to the cervix secondary 
nodules were found in the corpus uteri, and reported illustrative 
cases. Polk 10 says: “Within the limits, the operation was the 
only one to do; it is not worth while to consider any other pro- 
cedure.” 
1 American Journal of Obstetrics, October, 1892, p. 584. 
2 American Journal of Obstetrics, April, 1892, p. 436. 
* British Medical Journal, January 10th, 1891, p. 58. 
4 Edinburgh Medical Journal, p. 1003. 
5 Transactions of the American Association of Obstetricians and Gynecolo- 
gists, 1890. 
6 Transactions of the American Association of Obstetricians and Gyne- 
cologists, 1889, p. 141. 
1 Buffalo Medical and Surgical Journal. 
8 Medical News, December, 1888, p. 702. 
9Nouvelles Archives d’Obstetrique et de Gynecologie, 1892. 
I ’'American Journal of Obstetrics, 1891, p. 878. 20 
JONES : COLPO-HYSTERECTOMY 
In my microscopical investigations I have often seen the lym- 
phatics stretching along through the tissues, conveying their bur- 
den of epithelia far away from the seat of origin, and depositing 
portions at varying points, which become new centres of infec- 
tion. No one can say how far these lymphatics have travelled, 
what has been their course, or where the deposits have been 
made. There is no method by which we can possibly tell how 
far the cancerous disease has advanced. With this doubt, this 
dread uncertainty, will any one dare remove only a part of the 
uterus, and possibly leave the most flagrant portion of the dis- 
ease? Can we subject a patient to so great a risk with so danger- 
ous a possibility? Yet no doubt, in innumerable instances, by 
high amputation all the disease has been removed. As an ope- 
ration it has doubtless done great good, saved the lives of many, 
and the operation has been sanctioned and practised by some of 
our most eminent surgeons.1 Still, must there not always be with 
it an increased cause for uncertainty ? 
Probably the strongest reason in favor of total hysterectomy is 
the fact that around every malignant growth there is an inflam- 
matory infiltration. Virchow a says: “Three to five lines be- 
yond the apparent limits the tissues are already in a state of 
disease and exhibiting the first traces of a new zone.” I have 
over and over again seen this inflammatory infiltration, have 
marked out the zone, and with high powers of the microscope 
have many times demonstrated beyond doubt that the inflam- 
matory corpuscles of this zone were changing to cancer epi- 
thelia; from being round they were becoming polyhedral in 
form. I have repeatedly watched this marvellous change into 
cancer epithelia. This inflammatory zone is really cancer- 
ous in its nature, and no operation for the removal of the tu- 
mor is complete unless all the zone of inflammatory infiltration 
is removed. This is the only safe method ; and in case of can- 
1 One case remained free from recurrence nine years after an operation by Dr. 
Sims in the Woman’s Hospital. In 1882 Dr. Baker reported that “out of ten 
cases operated upon by high amputation, when the diagnosis was confirmed by 
the microscope, six were alive after four years ; after ten years, five of them, or 
fifty per cent, were alive and perfectly well’' (American Journal of Ob- 
stetrics). Both Dr. Sims and Dr. Baker have done most excellent work and 
deserve the thanks of all. 
2 “ Cellular Pathology.” FOR MALIGNANT DISEASE. 
21 
cer of any part of the uterus it becomes almost a necessity to 
remove the whole organ. When all the surrounding inflamma- 
tory infiltration is not taken away the disease surely returns, or 
rather continues. As verifying this, it has been repeatedly 
noted and stated by observers that recurrence almost uniformly 
takes place near the cicatrix. Heidenhaim says: “The recur- 
rences are on the margin of the old incision.” J. Mar- 
shall,1 of London, says : “ The new growth is exactly between 
the cicatrix and healthy tissue.” H. C. Coe 3 has observed that 
“ the early recurrence of the disease is nearly always at the 
border of the cicatrix.” Virchow3 has also stated that recur- 
rence usually takes place in this zone. 
The almost uniform recurrence so near the original disease is 
doubtless because all the zone of small cellular infiltration had 
not been removed. This surrounding infiltration is part and 
parcel of the abnormal growth, is cancerous in its nature, and 
should invariably be included with the tumor in any operation 
that may take place. Surgeons have long recognized that for 
the safety of a patient a large area of tissue around a growth 
should be condemned. Macewen4 says : “ There is tissue, beyond 
the mere hard border of the tumor, which is already implicated 
by epithelial elements.” J. Sims Woodhead6 says: “From a 
careful microscopical examination of many hundreds of cancer, I 
am firmly of the opinion that many surgeons make the mistake of 
not removing sufficiently freely either the tissues in which a can- 
cerous growth has made its appearance, or the lymphatic glands 
associated with the organ in which the cancer is developed.” 
Shrady® says in unmistakable words: “ I am firmly convinced 
that operations, as a rule, are not radical enough to insure a 
complete and thorough removal of the disease.” Butlin 7 says : 
“ It is always necessary to remove some of the surrounding tis- 
sue, in some instances a very wide area, in order to prevent a 
1 British Medical Journal, November 23d, 1889, p. 1144. 
* American Journal op Obstetrics, June, 1890, p. 594. 
3 Archives. 
4 Glasgow Medical Journal, 1886, p. 289. 
5 British Medical Journal. 
6 Medical Record, January, 1887. 
1 “Operative Surgery for Malignant Disease.” By H. C. Butlin, Professor 
of Pathology in the Royal College of Surgeons, London. 22 
JONES : COLFO-HYSTERECTOMY 
recurrence of the disease.” J. Marshall,1 of London, repeats: 
“ Do not be timorous and hesitating, do not care about a scar, 
but sweep away to a great distance ; it does not matter about de- 
formity—it is the preservation of the patient’s life.” 
Sir Spencer Wells 2 remarks : “It will sometimes be the pain- 
ful duty of the surgeon to urge upon a patient to sacrifice a 
limb in the hope of saving life ; and if this advice is followed 
before infection of the glands has taken place the result has 
often proved the soundness of the advice ; while too great de- 
lay, or want of earnestness in urging submission to so serious an 
alternative as the loss of a limb must always be, may lead to pro- 
tracted suffering and inevitable death.” 
With these considerations, and especially recognizing the in- 
flammatory infiltration that is around every malignant growth, 
the boundaries of which we cannot tell, does it not follow that in 
every case of cancer of the cervix complete hysterectomy be- 
comes the only safe and conservative procedure ? Keith3 says: 
“JSTo one nowadays thinks of removing a bit of cancerous 
mamma.” E. E. Montgomery,4 of Philadelphia, asserts “ that in 
all cases of cancer, when confined to the uterus, whether of the 
body or cervix, vaginal hysterectomy is the only justifiable 
operation.” 
Entire hysterectomy is not only a safer procedure as to re- 
moving all the disease, but it may be made almost as simple an 
operation as high amputation. Indeed, in many instances it is 
less difficult, attended by less danger, less shock, has a more 
rapid convalescence, the wound heals more promptly, and, finally, 
this operation gives more certain results as to a permanent cure. 
Schatz, who has performed both operations, wrote in 1883 : 
“ The danger of high amputation does not seem to be much 
smaller than total extirpation.” C. A. L. Reed,5 of Cincinnati, 
says : “High amputation is a more difficult and more dangerous 
1 “ Morton Lectures on Cancerous Diseases,” November 23d, 1889. 
2 British Medical Journal, December 8th, 1888, p. 1266. “ The Morton Lec- 
tures on Cancer and Cancerous Diseases,” delivered at the Royal College of 
Surgeons, England, November 29th, 1888. 
3 British Medical Journal, January, 1889, p. 57. 
4 Transactions of the American Association of Obstetricians and Gynecolo- 
gists, p. 194. 
5 Buffalo Medical and Surgical Journal. FOR MALIGNANT DISEASE. 
23 
operation than vaginal hysterectomy.” E. W. Cushing1 says : 
“ Total extirpation is not more difficult and very little more 
dangerous than the really high amputation of the cervix, and it 
affords greater immunity from relapse.” Krug2 says : “ I can- 
not concede that high amputation, done in the proper way, is, 
as a rule, a less difficult operation than vaginal hysterectomy. 
I like to be seen in the front rank of aggressive surgery when- 
ever malignant disease is conceded.” J. E. Janvrin,3 with regard 
to high amputation and vaginal hysterectomy in cancer of the 
uterus, says he has found the latter operation decidedly easier to 
perform. Prof. Sinclair,4 of Manchester, states that “although 
vaginal hysterectomy is called major, it is perhaps less dangerous 
than some of the so-called minor operations.” Fatal primary 
hemorrhage has followed excision of the cervix uteri. T. A. 
Emmet6 says “ he has removed the cervix in several cases in 
which the hemorrhage was as profuse as a post-partum hemor- 
rhage; in one case the blood ran through the bed and upon the 
door.” Krug 6 finds “it is more difficult to control hemorrhage 
in high amputation.” Coe says “in one of his cases the hem- 
orrhage which arose when he started to do high amputation 
proved so great that he abandoned the procedure.” Franklin II. 
Martin,7 of Chicago, says: “The most tedious operations which 
I have seen in surgery have been amputations for cancer of the 
cervix. The most bloody have been these same operations. I 
believe the mortality of vaginal hysterectomy will soon become 
so low that the unsurgical procedure of high amputation for 
cancer will be considered no longer justifiable.” lie further 
says : “ Vaginal hysterectomy is the most justifiable surgical pro- 
cedure we yet know of for the cure of cancer of the uterus.” 
J. C. Cullingwortli,8 of London, stated that, after careful study 
of vaginal hysterectomy in Germany and high amputation in 
England, he had found that the mortality of the former was five 
per cent, while that of the latter was seven per cent. 
1 American Journal of Orstetrics, April, 1892. 
2 Ibid., p. 621. 
3 Ibid., 1890, p. 646. 
4 London Lancet, May 17th, 1890. 
4 American Journal of Obstetrics, Supplement, March, 1882, p. 68. 
« Ibid.. 1890, p. 635. 
1 “ A Plea for Early Vaginal Hysterectomy for Cancer of the Uterus.” 
Journal of the American Medical Association, January 21st, 1891. 
4 Transactions of the Obstetrical Society of London. 24 
JONES : COLPO-HYSTERECTOMY 
Martin 1 says: “ Out of twenty-eight women on wTliom I have 
operated only two have remained free from relapse for somewhat 
over a year, and have then in a short time succumbed to the dis- 
ease, although I repeatedly excised and destroyed the incipient 
recurrence most thoroughly.” Hofmeier has forty-live per cent 
of permanent recoveries from high amputation, while Martin, 
from entire extirpation, has seventy per cent. John Williams 
says : “ Supravaginal amputation gives better results ” ; yet Wil- 
liams did supravaginal amputation four times, and the only pa- 
tient who recovered died a month after of fecal iistula high up 
in the small intestines. Krug2 goes still further, saying : uTo 
my mind there is absolutely no place for high amputation in 
cancer of the womb. As compared with vaginal hysterectomy, 
it is more unreliable, more difficult, and more dangerous.” 
The constitution of a woman seems to be more tolerant of 
hysterectomy than of any other grave operation connected with 
the pelvis or the abdomen. After this operation I have seen 
patients lie perfectly at ease, comfortable, and as if relieved, re- 
minding one of Schroder’s remark that “ a woman, after total 
extirpation of the uterus through the vagina, resembles rather a 
puerpera after a post-partum hemorrhage than a patient who 
has just experienced a severe operation.” T. Gaillard Thomas3 
tells of “ a young woman who had given birth to a child eight 
years previously. While making a violent effort at rolling ten- 
pins, suddenly felt something give way within her, after which 
she suffered the most intense pain. Dr. Willard Parker, being 
called to see her, coincided with the opinion of the attending 
physician that a polypus had been suddenly expelled and was 
hanging in the vagina. lie removed the whole mass, when, to 
his surprise, he found he held in his hand the inverted uterus 
with its tubes and ligaments. The patient recovered without 
any bad symptoms.” I am informed upon reliable authority 
that a woman in Maine, long annoyed with the protruding or- 
gan, one day, in her desperation, seized a knife and cut it off. 
She held the cut tissues firmly till hemorrhage ceased, then 
went on wTith her hoeing, and suffered no after-inconvenience. 
1 Annals of Gynecology. 
3 Transactions of the American Association of Obstetricians and Gynecolo- 
gists, p. 201. 
* “ Diseases of Women,” 1868, p. 339. FOR MALIGNANT DISEASE. 
25 
Even if high amputation were as efficient and attended with 
no possible danger, where could be the advantage of leaving a 
portion of the uterus ? Can it in any way be of any service ? Is 
it notan added danger ? Some say “it may give a woman a 
chance of conception.” That would certainly seem a sufficient 
reason, but such parturitions are apt to result in the death of the 
mother as well as the loss of the child. 
Dr. A. Vander Veer,1 of Albany, N. Y., in his paper on the 
management of cancer complicated with pregnancy, said : “ Out 
of nearly three hundred women suffering from cancer of the 
uterus and in labor, fifty-two per cent died undelivered or never 
left their beds; and of children only thirty-three per cent were 
born living, hardly twenty per cent lived until the mother left 
the childbed.” Dr. Vander Veer therefore concludes that total 
extirpation should be the rule and the operation should be done 
at the earliest moment. 
It is also to be noted that pregnancy, or any change of tissue 
or inflammatory action, causes the malignant disease to advance 
more rapidly, and labor at term may be accompanied by the 
most disastrous consequences. In 1886 Dr. Charles Jones was 
called to a case of confinement. The cervix was one hard mass 
of firm, unyielding cancerous infiltration. Dr. J. B. Goffe was in 
consultation. The physicians did everything possible to save the 
patient, but finally had to resort to abdominal section. Both 
mother and child perished. If hysterectomy had been done 
early in gestation the mother, at least, would have been saved. 
The child would have been lost in either case. 
C. A. L. Heed2 tells of a similar instance : “Numerous incisions 
were made in the cervix, forceps were applied, labor completed. 
Mother and child alike perished.” In the British Gynecological 
Society, November 13th, 1889, Dr. B. Fenwick 3 showed a preg- 
nant uterus, at about the third month, removed by hysterectomy 
for cancer of the cervix. “ Two years previously the cervix had 
been cauterized; six months later malignancy became more 
manifest and the cervix was amputated. Six months after the 
patient was found to be two months pregnant. It was decided 
1 New York Journal of Gynecology and Obstetrics, July, 1892. 
2 Buffalo Medical and Surgical Journal. 
8 British Gynecological Journal. 26 
JONES : COLPO-HYSTEKECTOMY 
to induce abortion, but it was impossible to discover any trace 
of a cervical canal in the hard remnant of the cervix.” 
Dr. Coe,1 in his article, observes : “ As soon as a diagnosis of 
a malignant growth is rendered certain, total extirpation of the 
uterus should be performed without delay.” JHe goes further 
and says: “ With the results of modern aseptic surgery before 
us, we are not justified in waiting until the diagnosis has been 
established beyond the shadow of a doubt and the patient’s 
health has been seriously undermined before we decide upon 
radical measures. I need only call attention to the fact that I 
performed total extirpation of the uterus in Cases 1 and 2, al- 
though by no means certain that I should find malignant dis- 
ease, and was much relieved to find my suspicions were justi- 
fied.” 
Many operations have been performed when it was not cer- 
tainly known that the disease was malignant. Krug states that 
“ he operated on one case in which there was a doubt about the 
diagnosis.” Dr. James B. Hunter 2 reported to the New York 
Obstetrical Society, December 20th, 1887, that “ he had suspected 
malignancy and so had performed vaginal hysterectomy ; that 
the specimen had not then been examined by the microscope.” 
Dr. Baldy,3 of Philadelphia, says : “ It is fast becoming the 
habit to operate on all suspicious cases.” Jonathan Hutchinson4 
said: “ I have held that cancer is, in its beginning, a local dis- 
ease, and to recommend operations so early that they might al- 
most rank as anticipatory.” The absence of pain, the absence 
of hemorrhage, or the absence of offensive discharges does not 
necessarily prove there is no malignant disease. E. E. Mont- 
gomery says : “ The uterus should be removed on suspicion; that, 
when there is a doubt which cannot be solved, the patient should 
have the benefit of this doubt.” Also, that he has removed 
some that were afterward found not to be cancerous. Hache 
makes mention of similar instances. “ Pichevin,6 in a clinical 
lecture, showed an interesting case in which an ulceration of the 
1 American Journal of Obstetrics, June, 1890. 
2 American Journal of Obstetrics, February, 1888. 
* Annals of Gynecology. 
4 Glasgow Medical Journal, 1886, p. 338. 
6 Nouvelles Archives d’Obstetrique et de Gynecologic, 1892, No. 2; quoted 
-from H. C. Coe, American Journal of Medical Sciences, July, 1892. FOR MALIGNANT DISEASE. 
27 
'cervix uteri had been diagnosticated as commencing epithelioma, 
and cauterized. The marked induration of the cervix and the 
decline of the patient’s health seemed to confirm the diagnosis, 
and hysterectomy was advised. A bit of the tissue was excised 
for microscopical examination, and it was found not to be ma- 
lignant. The true condition had been masked by cauterization.” 
Dr. Coe 1 says “ he has examined uteri removed by eminent 
surgeons in this city in which there was no malignant dis- 
ease at all, the condition being simple erosion of the cervix.” 
lie said at the meeting of the American Gynecological Society, 
September, 1892, that “ he had examined several uteri removed 
for supposed cancer which did not exist.” Landau 2 admits that 
“ he as well as other surgeons knows of cases of removal of the 
uterus for beginning epithelia of the cervix in which the condi- 
tion was found to be simple erosion, and of other cases in which 
adenoma or intra-uterine polypus was mistaken for corporeal 
epithelioma.” 
Better remove a few with no malignant disease than to leave 
•one cancerous uterus, and a patient with the awful risk of dying 
from a condition that the surgeon could have remedied. T. A. 
Emmet,3 speaking of cancer of the uterus, said : u In this disease 
there should be no delay in operating, and the patient should 
always have the benefit of a doubt and be relieved of any suspi- 
cious growth.” There is one way to settle the question as to 
malignancy and clear up all doubt, and that is by a microsco- 
pical examination. Such examination should in every instance 
be made. It will prevent all mistakes and possibly subsequent 
regrets.” Schatz4 says: “ In the beginning a malignant growth 
cannot be distinguished from an extensive erosion,” so he ad- 
vises that a piece of the cervix should be excised and examined 
microscopically. 
I had one case which gave, in the history, symptoms, and 
naked-eye appearances, every indication of being malignant. The 
woman was 50 years of age ; had an indurated, ulcerated cervix 
and bloody discharges. I had no doubt of malignancy ; but, as 
is my uniform rule, I submitted a portion of the diseased tissue 
1 American Journal of Obstetrics, 1890, p. 645. 
2 American Journal of Medical Sciences, October, 1889. 
8 “Principles and Practice of Gynecology,” p. 514. 
4 Zeitschrift fur Geburtshiilfe und Gyniikologie, Band xiii., Heft 1. 28 
JONES : COLPO-HYSTEKECTOMY 
to a careful microscopical examination. The disease proved to be 
benign, and the subsequent history of the patient confirmed the 
diagnosis. Without the microscopical examination I should cer- 
tainly have considered it my duty to have removed the uterus. 
The patient submitted entirely to my judgment, as every pa- 
tient for whom I have ever performed an operation has done. 
In many cases it is impossible to tell certainly without a 
microscopical examination. Dr. Playfair 1 mentions an instance 
where, “ a soft, fungating mass of malignant disease filling the 
uterine cavity, he suggested the possibility of extirpation. Three 
years after he met the lady’s medical attendant, who stated that 
she was then well and in comparative good health.” A short 
time since Dr. Charles N. D. Jones, in New York, for prolonged 
and repeated hemorrhages, curetted a uterus, after which the 
patient seemed to be doing well, hemorrhage stopped, and he 
and the attending physician supposed she would have no fur- 
ther trouble. Still, Dr. Jones had the scrapings examined micro- 
scopically. This was done by Dr. C. Heitzmann; the disease 
proved to be small round-celled sarcoma. A few days after, 
when the uterus was successfully removed, the sarcoma was 
found to be located in the fundus near the entrance of the 
left Fallopian tube. But for this microscopical examination the 
woman would have perished. She is now doing wrell. 
John Williams,3 in the Harveian lectures, describes cases of 
the disease in the earliest stages, when the diagnosis was ren- 
dered possible only by the microscope. E. W. Cushing3 has 
well said : “ The microscope is of the greatest service. In some 
cases the diagnosis can only be made by it ” ; adding, when the 
diagnosis becomes easy, the disease has usually progressed to a 
state where operation is difficult, or perhaps impossible. Dr. 
Boldt4 expresses the idea that “malignant disease can be posi- 
tively diagnosed in its early stages only by employing the 
microscope.” Huge and Yeit report numerous cases in which 
the development of malignant disease of the portio vaginalis was 
revealed by the microscopical examination of excised bits of tho 
1 Transactions Obstetrical Society of London, 1885, vol. xxvii., p. 42. 
2 British Medical Journal, January 8th, 1887, p. 50. 
3 American Journal op Obstetrics, April, 1892, pp. 435-487. 
4 “ Vaginal Hysterectomy for Cancer of the Uterus,” American Journal, 
of Obstetrics, October, 1892. FOR MALIGNANT DISEASE. 
29 
■suspected tissue long before palpation and inspection furnished 
evidence of the true condition. Wylie‘says “the first thing 
he does is to submit portions to a good pathologist for exami- 
nation.” Greig Smith8 gives the same advice, and insists that 
“ when diagnosis is doubtful, granulations should be removed 
and examined by the microscope.” 
A. Martin,3 of Berlin, says: “ The recognition of the early 
stages occasions very extraordinary difficulties. All the clinical 
symptoms which are referred to as indicating malignant disease 
may fail us; no peculiarity of the result of digital examination 
helps to give the necessary certainty, which at present we can 
gain only by microscopical examination.” lie warns against 
wishing to make a diagnosis based on the results of digital exami- 
nation and on the clinical symptoms, and says elsewhere: “The 
possibilities of a diagnosis can only be attained by scraping off 
pieces of the mucous membrane, as described above, and submit- 
ting them to microscopic examination”; adding, “when the 
presence of carcinoma is indubitably established by the micro- 
scope, to perform the extirpation of the whole uterus.” Prof. 
Lane4 says : “ I verified the disease with the microscope, and in 
every case it reached much further in than it seemed from the 
outside.” 
Dr. Lewis Pilcher5 says : “ In view of the great difficulties of 
diagnosis, it must in any case be required in all reports of 
recoveries that the actual condition be determined by the help 
of the microscope. The careful snrgical statistician of the pre- 
sent and of the future is compelled to exclude from all considera- 
tion in his studies and from his conclusions every case in which 
the character of the diseased tissue removed has not been exam- 
ined and certified to by a pathologist of recognized position. 
The lack of such pathological testimony requires us to reject a 
large proportion of the reports that have hitherto been made of 
the results of operation.” 
I agree entirely with Dr. Pilcher. A microscopical exami- 
1 International Journal of Surgery, 1891, p. 190. 
3 “ Abdominal Surgery.” 
3 “ Pathology and Therapeutics of the Diseases of Women.” By A. Martin. 
Translated by Ernest W. Cushing. Second edition, p. 810. 
4 Gynecological Transactions, 1888, p. 207. 
5 “ The Ultimate Results of Operation for Removal of Uterine Append- 
ages.” 30 
JONES : COLPO-HYSTERECTOMY 
nation is essential not only for certain diagnosis and to obtain! 
reliable scientific data, but justice to the patient demands it. 
Besides, the microscope shows the exact pathological changes 
that take place in the structure of various organs, and so gives 
new light as to the nature of disease, and will thereby help in 
finding a means of prevention and cure. Fully impressed with 
the seriousness and importance of this subject, I was the more 
surprised when, on one occasion, I heard a Brooklyn surgeon, 
Dr. A. J. C. Skene, when asked,“ What aid to a surgeon practising 
gynecology is the microscopical examination ”—of two of the 
most vital structures of woman’s genital organization, viz., the 
tubes and ovaries—answer, “ None whatever.” “Why not?” 
“ Because you cannot submit them in the living subject to micro- 
scopical examination ; it is only after they have been removed 
that they can be examined. It is only an aid for the examina- 
tion of surfaces ; it is utterly useless in ovarian diseases.” 
Yet all great surgeons the world over are earnestly looking to 
the teachings of the microscope to know more of the minute 
anatomy of each and every organ, the pathological changes that 
may occur, the nature of these changes, so that they may learn 
more of the etiology of disease, how to prevent, cure it, or 
check its ravages. All want to help suffering humanity, and all 
are interested in looking into these teachings. Most of the dis- 
coveries in pathological anatomy are from microscopical re- 
searches. Indeed, the whole science is founded upon this. By 
microscopical researches Virchow's Archives have reached one 
hundred and twenty-nine volumes. It is just as interesting to 
look at the thirty-nine volumes of Arch iv fur mihroskojpische 
Anatomic. Paget, in his “ Surgical Pathology,” gives repeat- 
edly the microscopical appearances. So Quain largely depends 
upon the teachings of the microscope for his “Elements of 
Anatomy.” The Morton, the Harveian, and other great sci- 
entific courses of lectures, instituted and endowed to increase 
our knowledge and extend the boundaries of medical science, 
have sought in the microscope the needed help. When John 
Williams gave his Harveian lectures on cancer he illustrated the 
subject by drawings made from the specimens and from micro- 
scopical sections. So John Marshall,1 F.R.S., in his lecture in 
the Morton course before the Royal College of Surgeons, had 
’British Medical Journal, November 18th, 1889, pp. 1141-1143. 31 
FOR MALIGNANT DISEASE. 
the specimens under the microscope, and in speaking of the 
great mysteries of the subject lie said, “ Here is work for the 
microscopist,” adding that “the most advances had been made 
through the study of structures. This,” said he, “ is the 
mode in which and through which knowledge has been in- 
creased in regard to these important diseases”; and still further 
emphasizing that “ it affords the key to the most material ad- 
vances in regard to the nature of disease.” 
Oliver Wendell Holmes,1 a great teacher and for many years 
professor in Harvard University, as far back as 1861, when 
speaking in regard to the value of the microscope to the great 
science of medicine, said: “The microscope has made a new 
science of the intimate structures of the organs; lias at the same 
time cleared up many uncertainties concerning the mechanism 
of the special functions. The minute structure of the viscera, 
the internal recesses of the animal system, were to the students 
of anatomy what the interior of Africa,” etc. 
To understand disease, and in many cases to intelligently 
treat it, we should understand the minute structure of an organ, 
and the pathological changes as the result of disease. 
What are the Limits of Vaginal Hysterectomy f—I have here- 
tofore held that colpo-hysterectomy should not be performed 
when the malignant disease has extended beyond the organ* 
I now believe surgeons quite right in removing the uterus 
for cancer, even though the disease may have extended to other 
structures; and if all the affected tissue, wherever found, can 
be removed, a cure may still be effected. In 1881 Dr. Paul F* 
Munde2 reported to the American Gynecological Society the re- 
moval of the uterus for cancer, which was afterward examined 
microscopically by Dr. C. Heitzmann, who stated: “Sections 
along the cut surface prove that the mucosa is in a condition 
of so-called small cellular infiltration, though cancer nests 
could not be detected ”; adding, “ should this view be correct, 
that this infiltration is the preliminary stage of cancer, no 
doubt recurrence will take place in your case within the next 
two years.” The disease in this patient was again recognized 
within seven months. Dr. Munde, in the above-mentioned 
paper, remarks: “A microscopical examination before opera- 
1 “ Medical Essays,” 1883, p. 231. 
2 Gynecological Transactions, 1884, p. 204 32 
JONES : COLPO-HYSTERECTOMY 
tion would liave revealed the futility of endeavoring to operate 
in sound tissue, and would have contra-indicated the operation/’ 
Would not a microscopical examination rather have revealed 
the extent of the disease, and have indicated to the operator 
how far to have extended his incisions and how much of the 
tissue was to be removed ; and to remove all the infected tissue, 
even if it required the extirpation of the whole vagina and 
still further surrounding structures % Prof. John Marshall,1 of 
London, says : “ Disregard the neatness of an operation, but 
sweep far away beyond what you really estimate as the seat of 
the disease.” A great surgeon in New York said to me: 
“ When an operation is once commenced make thorough work.” 
Dr. J. E. Janvrin,2 in his paper on “Vaginal Hysterectomy,” 
says : “ The operation should be performed, even if the disease 
has extended beyond the uterus, upon the vaginal mucous 
membrane or vaginal wall, or to the uterine adnexa.” Riche- 
lot :3 “If the disease has extended to neighboring organs 
it can still be readily removed by piecemeal {par morcelle- 
menty* 
When it is impossible to remove all the diseased tissues, an 
operation may stay the progress of the disease, prolong the 
patient’s life, and lessen her suffering. Ericlisen,4 in his work 
on “Surgery,” remarks: “The surgeon may sometimes operate 
in order to give the patient ease from present suffering, or per- 
haps with a view of prolonging life, even if he can have little 
expectation of effecting a cure. I am decidedly of the opinion 
that, if cancer cannot be actually cured by extirpation, life may 
be prolonged and health improved by the operation.” E. W. 
Cushing6 says: “ If the disease shows a tendency to spread 
toward the vagina there is great liability to recurrence, but that 
is no reason for not giving a woman her only chance. When it 
is surmised, but not known positively, that all the disease cannot 
be removed, the operation ought to be performed.” 
1 British Medical Journal. 
2 Medical Record, July 9th, 1892. 
’Revue medico-chirurgicale des Mals des Femmes, December, 1891. 
4 Eighth edition, vol. i., p. 1004. 
5 “ Vaginal Hysterectomy for Cancer.” Read before the Medical Society of 
the State of New York. FOR MALIGNANT DISEASE. 
33 
Schauta considered it questionable whether we should not 
“give the patient the moral support afforded by an operation, 
even if we are quite sure that we cannot go beyond the disease.” 
lie also questions whether we are not able to prolong life some- 
what by diminishing pain and suffering. Munde1 well says 
of his case above referred to: “ The patient has, I think, been 
well repaid for the risk she ran; she had little or no suffering 
after the operation, and enjoyed nearly a year of freedom 
from hemorrhage, discharge, pain, and disagreeable local treat- 
ment”; adding, “ were I to meet with a precisely similar case 
I should give her the same chance for relief.” Martin* says: 
“ By an operative treatment we undoubtedly best remedy the 
symptoms of these so-called inoperable cases, and at any rate by 
this means we uphold the failing courage of these unhappy ones 
better than by purely medical prescriptions.” G. F. Shrady, 
in speaking of operations for malignant diseases in general 
surgery, says : u It is better that we run the chance of recurrence 
than that we take the other alternative of allowing the disease 
to go beyond us and kill the patient, for recurrence generally 
means slower growth and less pain. Allowing that the odds are 
against us, we should not be discouraged in giving our patients 
their only chance. Practically the operation comes to this. 
Otherwise our patients must voluntarily resign themselves to the 
inevitable.” Shrady 3 refers to Weir’s report of a case in which 
the right breast was amputated by dames Ii. Wood in 1856. In 
1887 Post amputated the left breast. In 1873 Weir removed a 
recurrent growth from the right side, and again in 1877 and 
1880. The patient finally died of the disease in 1881. This 
covers a period of twenty-six years. 
Operating on hopeless cases may give poorer statistics, but the 
welfare and comfort of the sick are of more importance than 
statistics. Besides, a separate table may be made for the recog- 
nized hopeless cases, of which there would be fewer if their con- 
dition could be known at an earlier period. Yet, in the face of 
these facts, one author4 has assured us that “ other methods of 
treatment, less dangerous than the extirpation of the uterus, are 
equally and even more useful.” 
1 Gynecological Transactions, 1884, p. 200. 
2 Annals of Gynecology. 
3 Medical Record, January 22d, 1887. 
4 A. Reeves Jackson, Transactions of American Gynecological Society, 1888. 34 
JONES : COLPO-HYSTEKECTOMY 
In so important a matter as this we should know; there 
should be no uncertain sound; we should he told what is right, 
and do only the best thing. The same author continues: “The 
alleviation of pain, the prevention and arrest of hemorrhage, the 
amelioration of offensive and acrid discharge, the maintenance 
of the general health, are all indications that may be met to 
some extent by comparatively harmless means.” 1 Are not these 
symptoms of cancer, and to be met by removing the cause ? How 
shall we alleviate pain? By narcotics? Besides doing the sys- 
tem great injury, are they not playwork in the face of so great 
an enemy? “Arrest hemorrhages.” Are we certain that we 
can do this ? How near may the cancer be to a large artery ? 
I have seen, under the microscope, the cancer destroying the 
walls of a great blood vessel. How long will a styptic or a 
tampon prevent its walls from breaking down or stay the march 
of the deadly disease ? “ Maintain the general health.” This is 
excellent and should be done by all possible means, but how long 
can the general health be maintained when cancer is preying 
upon the vitals ? 
The author says further : “ Other methods than excision of the 
entire organ—as, for example, the sharp curette, knife, scissors, 
caustic, cautery, etc.—are capable of doing very much good, lessen- 
ing suffering, and prolonging life.” Certainly we want anything 
that will “do good, lessen suffering, or prolong life”; but are 
not these procedures attended with danger, and are they always 
useful? B. Jesset2 said: “Caustic in this or any other form of 
disease is unreliable, and in some cases harmful.” Meigs3 says 
“he has never seen caustics do much permanent good.” A. H. 
Cordier4 says: “All escharotics, caustics, and tinkering should 
be condemned in treating these cases ; they never cure, but often 
make complications.” Joseph Taber Johnson 6 says : “Caustics 
and minor operations do little good and only prolong the patient’s 
1 This reminds one of what Graily Hewitt said in 18G8, viz.: “There are 
three conditions to the relief of which our attention is directed, the pain, the 
hemorrhage, and the discharge, besides maintaining the functions of the body 
in a state of activity.” But Graily Hewitt does not mention these as supersed- 
ing surgical measures. 
2 British Gynecological Society, January 23d, 1890. 
* “ Diseases of Women,” 1868. 
4 Annals of Gynecology and Surgery, January, 1892, p. 524. 
6 American Journal of Obstetrics, June, 1888, p. 635. FOR MALIGNANT DISEASE. 
35 
suffering.” West and Duncan 1 say : “Asa general rule, partial 
destruction has been followed by a more rapid development of 
the disease ”—this was said at a time when caustics were trusted 
and tried faithfully—adding, “I have not been able to attribute 
to the actual cautery any dela}' in the progress of the evil.” T. 
S. Lee said : “ Caustic is our only resource, but I have never seen 
it do much permanent good.” A. Martin2 says : “ I have now 
abandoned all caustic applications and use of the actual cautery, 
in any form whatever, even when the disease is yet entirely 
localized; I believe that a permanent result cannot be attained, 
even in the first stages, by any cauterization, however deep.” 
Wylie3 said: “I would never burn this tissue with caustic, 
with the galvanic cautery, or anything that would destroy the 
mucous membrane.” Martin, of Chicago, says : “ When the 
cautery is employed to its fullest extent it will still fall short of 
what is accomplished by total removal.” If. C. Coe4 says: “ The 
sharp curette or the galvano-cautery, with which we only work 
in the dark, and incur a certain risk of perforation in the uterine 
wall, and causing fatal peritonitis.” He remarks elsewhere that 
“ he'believes, every time that adenoma uteri is attacked with the 
cautery, it simply returns in a more malignant form ; that the 
use of the galvanic cautery may be less objectionable, but it is a 
blind procedure.” He tells of one of his patients, on whom a 
palliative operation simply hastened her death; or of another 
case he says: “ There is no doubt that a delay of a few months, 
with one or two more palliative operations, would have resulted 
fatally.” lie quotes Furst as saying that “ palliation does more 
harm than good, simply aggravates the matter.” 
The electric cautery has certainly the power of destroying the 
tissue, as has the actual cautery, or as has arsenic, or as have 
many of the secret cancer preparations. Most of the latter are 
made up of arsenious acid, and their use is not only tedious but 
is necessarily accompanied by great distress and suffering. One 
woman, who I knew was by some secret preparation having a 
1 “ Diseases of Women.” 
2 “ Pathology and Therapeutics of the Diseases of Women.”. By A. 
Martin. Translated by Ernest W. Cushing. Second edition. 
3 International Journal of Surgery, 1891, p. 190. 
4 “ The Limit of Vaginal Hysterectomy for Cancer of the Uterus,” Ameri- 
can Journal of Obstetrics, June, 1890, p. 596. 36 
.TONES : COLPO HYSTERECTOMY 
cancer of the mammary gland removed, suffered more at each 
application than she would have done by the radical operation, 
and finally she succumbed before the work was accomplished. 
When the great John Hunter on one occasion was called 
upon to decide the propriety of using one of these secret prepara- 
tions, he put the following question to the maker of the prepara- 
tion : “ What do you intend to do with your medicine?” “To 
cure the patient.” “ Let me know what you mean by that ? Do 
you mean to alter the diseased state of the parts, or do you mean 
by your medicine to remove the parts diseased?” “ I mean to 
destroy them.” “ Well, then,” said John Hunter, “ that is no- 
thing more than I, or any other surgeon, can do with less pain to 
the patient.” Sir Spencer Wells 1 says : “ We have no reason to 
fear a comparison between what we can do by fair and open 
means and what can really be done by any cancer curer or secret 
remedy.” W. M. Polk3 “ held that if the cautery would destroy 
the cancerous disease, tbe knife would do the same” ; adding, 
“ the diseased tissue could he cut out if it could be burnt out.” 
Cancer-cure preparations and cautery all work in the dark and 
are “ blind procedures.” John Marshall3 says : “ A very sweep- 
ing use of the knife is better, I would say, than any cautery, any 
electricity, any form of temporizing with caustics, with pressure, 
with cold, or any such means. Electricity, we must remember, 
will only destroy what it reaches ; it will ultimately be regarded 
as inferior to the knife. The knife, which sounds so cruel but 
which is not, is the most feasible method of removing these 
things.” 
John Byrne,4 in 1889, reported to the American Gynecolo- 
gical Society that he had up to that time treated three hundred 
and sixty-seven cases of cancer of the uterus by the galvano- 
cautery. He stated that “ one hundred and fifty-one, or fifty- 
four per cent, were lost to observation before the expiration of 
one year.” So the result in nearly one-half the cases is not 
known. Still we understand that three hundred and sixty-seven 
women had “ cauterization ” and more or less “ excavation of 
the uterine cavity.” His methods are: “ Every part of the 
1 “ The Morton Lecture on Cancer and Cancerous Diseases,” November, 1889. 
* American Journal op Obstetrics, 1890, p. 634. 
3 British Medical Journal, December, 1888. 
4 Gynecological Transactions, 1889. FOR MALIGNANT DISEASE. 
37 
cavity should he gone over repeatedly,” “ the ragged borders of 
the excavation”; “no raw spots should he permitted to escape the 
cautery ” “ till all are charred, regardless of apparent limita- 
tions,” till there is “ an entire excavation and cauterization of 
the uterus”; then a “ firmly rolled tampon should he inserted 
within the charred cavity.” Says Dr. Byrne : “ The full extent 
to which cauterization may he carried with impunity, and short 
of devitalizing peritoneal or other adjacent structures, I am not 
prepared to say.” 
But even though the greater part of the uterus is reduced to 
a “ black char,” there may yet he cancer nests. Why not burn 
a little more, “ regardless of apparent limitations,” or short of 
“ devitalizing the peritoneal or other adjacent structures ”—burn 
even “ beyond the supposed danger line,” destroying as much 
of the affected organ as can be safely spared—give “ a thorough 
and fearless cauterization”? Why not at once make it “entire 
•extirpation,” and save the patient, though the method may be 
uncouth and the procedure somewhat unsurgical? 
But it is marvellous to me how so many cases of cancer of the 
uterus could be diagnosed without any microscopical examina- 
tion. In the whole article I do not read of any reference being 
made to a microscopical examination, or to his methods of diag- 
nosis, except in one place he remarks : “ In all cases of indura- 
tion, destructive ulceration, or outgrowths of the cervix uteri of 
a malignant nature, or believed to be so.” “ Believed to be so.” 
Can that be depended upon as a method of diagnosis ? By the 
microscope we could tell positively. Dr. Byrne says of a case, 
April, 1879 : “ She was found to have a rapidly developing car- 
cinoma.” How could he know this certainty without a micro- 
scopical examination? On the preceding pages he speaks of 
“ a well-marked cancer of the cervix which was removed by the 
galvano-cautery.” If it was “ well-marked cancer of the cer- 
vix,” who could say that cancer had not extended far beyond ? 
Schauta, of Prague, says : “ Microscopically and clinically the 
diagnosis of the boundaries of cancer is impossible ”; and he 
.adds, “ for this reason a radical operation is always indicated.” 
Dr. Byrne continues in regard to the preceding patient: “ On 
referring to the hospital records it was found that this patient 
had been attacked with pelvic pains and hemorrhage live months 
after her third confinement.” Would this necessarily indicate 38 
JONES : COLPO-1IYS'l'ERECTOMY 
cancer? Do not such symptoms frequently follow lacerated 
cervix and subin volution, with possible misplacement of the 
uterus? And many women so affected maybe restored to health 
by curettage and repairing the puerperal injuries, and so be 
enabled to have a half-dozen or more children. One cannot 
calculate how many little ones by this “charring” and cauteri- 
zation have been prevented from coming into the world, how 
many possible little children have been destroyed, or how many 
prospective families have been made to vanish! Charles D. 
Meigs,1 the clear diagnostician, an eminent professor in Phila- 
delphia, said in 1859: “ I have certainly met, in the course of 
fifty years, with several cases of diseased uteri which I had the 
greatest reason to suppose were cancerous, but which yielded 
to persevering treatment and ended in perfect recovery of 
health.” Dr. Playfair,2 in the London Obstetrical Society, 
said : “ He would be a bold man wbo would venture positively 
to distinguish between certain changes in the cervix due to 
hyperplasia, and the early stages of carcinoma.” 
Dr. Byrne’s statistics state: “The disease was limited to the 
portio vaginalis in fifty-nine cases.” How could any one pos- 
sibly discover or know this? Pozzi says: “No possible method 
of investigation can tell whether the cancer is limited to the 
cervix or not.” Indeed, after all, have we any proof that all 
the “ three hundred and sixty-seven patients” really had cancer? 
Dr. Byrne’s statistics further state: “The entire cervix was 
affected in eiglity-one.” Could any human knowledge say that 
the disease had not extended beyond? Even if the whole cervix 
is removed and most of the fundus, “ regardless of apparent 
limitations,” cancer epithelia and cancer nests may still be left. 
Dr. Byrne speaks of amputation by the heated loop or knife at 
or above the vaginal insertion. T. A. Emmet3 says: “ Let the 
operation be done with scissors, but never with the galvanic 
wire or the ecraseur. I most strenuously object to these instru- 
ments.” Dr. Byrne continues: “ Amputation of the cervix,high 
or low, is worse than useless, unless followed by a thorough dry 
roasting of all the exposed surfaces.” Dr. Thomas Keith 4 says: 
1 “ Diseases of Women,” p. 333. 
2 Transactions of the Obstetrical Society of London, vol. xxvii., p 42. 
* “ Principles and Practice of Gynecology,” p. 502. 
4 British Medical Journal, January, 1891, p. 58. FOR MALIGNANT DISEASE. 
39 
“ To remove as much of the uterus as possible without opening 
into the peritoneal cavity, and then to follow up the disease of 
the cavity by the free use of the cautery, seems to me to he mon- 
strously bad surgery.” Erichsen 1 asserts that “ the wound left 
by the galvanic ecraseur is more likely to slough, and secondary 
hemorrhage much more frequently occurs, than after the use of 
tlie simple ecraseur.” Mr. Jesset,2 in speaking of supravaginal 
amputation of the cervix, said, December, 1892, “lie preferred 
scissors or the knife to cautery.” Dr. Herbert Spencer,3 on 
the same occasion, referring to Dr. Byrne’s use of the galvanic 
cautery, said “lie agreed with Mr. Jesset that removal by knife 
was preferable to removal by cautery or any other method.” 
In the above remarks I have not intended to criticise Dr. 
Byrne’s work. I am a learner, earnestly seeking to know the 
most excellent way. Our aim is to save life. We are desirous 
to do the best for each and every case. The question is not the 
operation or the methods, but how we can certainly and most 
successfully relieve suffering, cure disease, and save from a cer- 
tain and impending death. I would most assuredly adopt the 
procedures of Dr. Byrne if I could believe they were best. 
Technique of Vaginal Hysterectomy.—This becomes a most 
interesting and important subject. Dr. Montgomery4 says: 
“ The methods of operating are almost as many as the number 
of operators.” Prof. P. Muller5 says: “The best method for 
vaginal removal of the whole uterus is still an open question. 
Two difficulties are met with : one, the long duration of the ope- 
ration ; the other, the uncertainty of controlling hemorrhage.” 
Martin6 says: “It is to be classed as one of the most difficult 
operative proceedings in abdominal surgery.” C. C. Lee said, 
at the New York Obstetrical Society, December 4th, 1883: “An 
operation which was at best exceedingly difficult to perform and 
extremely dangerous to life.” The Lancet says, March 26th, 
1887: “In uterine cancers the operator is always obliged to cut 
clear of diseased organs through structures which lie in the dark 
1 Erichsen’s “Surgery,” vol. i., p. 1009. 
a Medical Record, January 7th, 1893, p. 29. 
3 Ibid. 
4 Annals of Gynecology, June, 1892. 
5 Centralblatt fur Gynakologie, 1887, No. 12. 
6Fenger, American Journal of Medical Sciences. 40 
JOXES : COEPO-HYSTERECTOMY 
or are at least difficult of access.” Fenger 1 says: “ As the opera- 
tion itself is so difficult and the time occupied in its performance 
so great, any suggestion by which the duration of any of the steps 
of the operation may be shortened and the operation facilitated 
should be accepted with gratitude. Even under the most favor- 
able circumstances it is a long and difficult operation.” Dr. A. 
Reeves Jackson 2 says : “The operation by any method is essen- 
tially difficult, tedious, and dangerous, and no amount of skill in 
the performance can make it easy or safe.” An editorial in the 
British Medical Journal3 says : “ Vaginal hysterectomy, always 
a troublesome operation on account of the want of free space 
for operating, is rendered tenfold more difficult and dangerous 
when dissecting any of the pelvic cellular tissue is undertaken.” 
Dr. E. C. Sterling* says: “The operation is one of great diffi- 
culty.” Reamy6 says: “Vaginal hysterectomy is a very dan- 
gerous operation.” 
Technique.—From the status of the operation, the procedure 
of others, and my own limited experience, I have been led to 
conclude that the operation could be very much simplified, made 
very much less difficult, and be very much less dangerous. 
The best and most natural mode of procedure has seemed to me 
to he the following: The patient having been prepared with 
equal care as for laparatomy and placed in the extreme lithotomy 
position, seize the cervix with strong forceps, bring it gradually 
down toward the rectum ; note the extent of the bladder; if 
necessary, pass a sound, to be certain of its boundaries ; make an 
incision on the anterior surface of the cervix near the boun- 
dary of the bladder, so as to be as far as possible from the can- 
cerous cervix; separate the vaginal tissue anteriorly, and, when 
reaching the anterior cul-de-sac, open into the peritoneal cavity. 
The peritonea] membrane and the mucous membrane of the 
vagina may be caught together by a stitch ; thereby the bladder 
is more securely protected, hemorrhage somewhat checked, and 
the stitch gives a convenient loop to hold out the membrane, 
1 Fenger, American Journal of Medical Sciences. 
2 Transactions American Gynecological Society, 1883. 
* May 21st, 1889, p. 1097. 
4 First half Transactions of American Association Obstetricians and Gyne 
cologists. 
5 Gynecological Transactions, 1883, p. 232. FOR MALIGNANT DISEASE. 
41 
that the uterus may be more easily approached. The fundus is 
seized by strong volsella forceps and brought out anteriorly. 
The left broad ligament is now at your hand, and can be easily 
secured by pressure forceps; or, what is better, ligate the top of 
the broad ligament and secure the lower portion with forceps. 
Delivering the uterus a little more, the right ligament is at 
your hand ; secure it in the same way. To separate the posterior 
vaginal attachments is the work of but a few minutes. Sew or 
clamp the posterior membrane, remove the sponges, and clean 
out the peritoneal cavity. 
I3y this method, systematically carried out, the operation may 
be made extremely simple; the time may be reduced one-half ; 
there will not be near the tax, danger, or shock to the patient; 
and in favorable cases and under favorable circumstances the 
work may be done in ten, twelve, fifteen, or thirty minutes. 
We know by other methods the best operators consume one, 
two, or more hours. 
Drainage.—I have usually inserted pieces of gauze, one end 
extending into the peritoneal cavity, thus making perfect drain- 
age; tampon the vagina with the same gauze, then wrap the 
whole part, the projecting forceps, etc., with large folds of ab- 
sorbent cotton covered with gauze. Place the patient in bed 
with a pillow under her knees, which will keep all secure. 
Some say leave the dressings on four or five days ; but evidently 
if these dressings are daily removed much substance which has 
drained from the peritoneal cavity is taken away. The dress- 
ings should be changed just as we frequently draw off a drain- 
age tube in abdominal section. I have found great advantage in 
changing the dressings twice the first twenty-four hours, and 
after that once a day. 
Assistants.—Fenger says, in his excellent article printed in 
The American Journal of Obstetrics, 1881: “Six reliable 
assistants are required in performing the extirpation.” I saw 
Martin do the operation, he had four assistants ; Leopold the 
same number. I have frequently thought the fewer the num- 
ber of assistants in any operation the better. Many surgeons 
tell us the danger of infection is increased by every added one. 
Thomas A. Emmet once said that “ by an accidental visitor 
1 Medical Record, February 7th. 42 
JONES : COLPO-HYSTERECTOMY 
touching one of his instruments lie believes he lost his pa- 
tient.'” On an important occasion Gill Wylie1 lately said, 
referring especially to the operation of laparatomy : “ My aim 
is to have just as few assistants touch the patients, or touch 
the instruments, or do anything, as possible. In my opera- 
tions one person is permitted to do that.” He added: “ I 
think the more progressive men have fewer assistants and 
nurses than they ever did before, the object being to avoid the 
da nger of sepsis.” Wylie further remarks : “ The aim is, and 
has been for years, to do away with as many assistants and 
as many persons around the patient as possible.” He said on 
another occasion: “ Ordinarily three assistants; for,” said he, 
“ of course the number of persons helping adds to the danger 
of infection.” I saw Dr. Baldy do a laparatomy in Philadel- 
phia, April, 1892, when, besides the etherizer, he had but one 
assistant—viz., the nurse, who stood opposite to him. He got 
along comfortably and successfully. He told me, January 19th, 
1893, for laparatomy he usually wished only one assistant be- 
sides the etherizer and a nurse. I saw Granville Bantock do a 
number of operations with only one assistant besides the ether- 
izer. I have seen G. P. Edebohls perform a number of ope- 
rations ; besides the etherizer he usually had two assistants. I 
saw Joseph Price do a most difficult laparatomy, January 
18th, 1893; besides the etherizer, who was one of his nurses, he 
had two other nurses to hand him the instruments and sponges 
as he wanted them. 
With almost equal ease colpo-hysterectomy can be done with 
a few assistants. Dr. Bantock 1 performed vaginal hysterec- 
tomy, September, 1889, with only one assistant. The case was 
complicated by omental adhesion to the fundus, hydrosalpinx, 
and a disease of the left ovary, which latter was removed. The 
patient recovered without a bad symptom. 
If the uterus is delivered anteriorly, no other opening being 
made, one can get along easily with two assistants. With my 
second and third I had two trained nurses to help ; one adminis- 
tered the ether, the other handed me the needed instruments, 
gauze, sponges, etc. Dr. Price said on the above-mentioned occa- 
sion that “ he trained his own nurses, and had rather have them 
1 British Medical Journal, November 29th, 1890, p. 1288. 43 
than nurses from any training school.” I am sure the two nurses 
we trained in the Woman’s Hospital in Brooklyn did as good 
work, and in some respects better, than any nurses I have ever 
seen ; and few physicians could administer the ether better, more 
carefully, or more successfully than either of these two nurses. 
/Shall the Vaginoperitoneal Opening he dosed?—Not closing 
it certainly allows of more perfect drainage. Some say there is 
nothing to drain. There is a vast amount. I have repeatedly 
found the gauze, cotton, and all completely saturated. A dis- 
eased uterus has been removed, the broad ligaments have been 
cut, in many cases parametric cellular tissue has been separated, 
and blood and debris have necessarily collected in the peritoneal 
cavity. There is necessity of the most thorough drainage. The 
success of this operation depends upon good drainage and secu- 
rity against hemorrhage. In three of my cases I removed a 
large portion of the broad ligament, considerable of the para- 
metric cellular tissue, and a portion of the vagina adjoining the 
cervix. Probably this liberal removal of surrounding tissue is 
what saved the patients’ life. A. II. Cordier,1 Kansas City, 
says : “ These cases always drain profusely.” 
Joseph Price2 says : “ It is surprising what a large amount of 
fluid escapes after vaginal hysterectomy ; it will soak through 
bandages and wet huge gauze pads. I have had cushions made 
two feet long and eighteen inches wide and four inches thick, 
of corrosive jute and gauze. These are sometimes soaked 
through in twelve hours.” E. W. Cushing 3 says : “ I am aware 
that attempts have been made to complete hysterectomy with- 
out drainage, tightly closing the wound. Martin began this 
way and lost a of cases, and then resorted to drainage. 
I have seen Olshausen close the opening, but he told me that his 
results were not what he should like.” Martin and others have 
used a T-shaped drainage tube. Some surgeons have suggested 
that pressure forceps will make sufficient drainage. I have 
found the most thorough and effective drainage secured by the 
use of a long slip of gauze entering the peritoneal cavity. With 
my fourth case I placed a drainage tube in addition to the piece 
FOR MALIGNANT DISEASE. 
1 “ A Plea for the Early Surgical Treatment of Cancer of the Uterus.” Read 
before the Obstetrical Society of Philadelphia, April, 1892. 
* Annals of Gynecology, June, 1892, p. 557. 
Annals of Gynecology, June, 1892, p. 555. 44 
JONES : COLPO-HYSTERECTOMY 
of gauze. When removed there was nothing in the drainage 
tube, but the gauze was fully saturated and had saturated the 
dressings beneath and around. 
How often should the Wound he dressed?—Many have re- 
commended that the dressings be not removed for five or six 
days. I have found the best results by removing dressings the 
same day, a few hours after the operation—and have always 
found them thoroughly saturated—and after the first day, once in 
twenty-four hours, till the wound was healed. The frequent 
change of dressings keeps the pulse and temperature down, pre- 
vents restlessness and danger of septicemia. E. C. Dudley 1 
says : “ In one of my own cases the gauze, removed at the end 
of forty-eight hours, was found extremely fetid, and after its re- 
moval a quantity of offensive secretions immediately came away 
which had been dammed back against the wound in conse- 
quence of the obstruction of the gauze.” These conditions 
were sufficient to have produced sepsis. Dr. James B. Hunter 2 
said he “had a case which died on the thirteenth day of septi- 
cemia ; the iodoform gauze was removed in forty-eight hours.” 
Greig Smith says : “ Tampons in the genital passages have of 
themselves a strong tendency to become putrid.” 
When shall the Bowels he moved?—Fenger says: “ It is nat- 
ural that we keep the bowels perfectly quiet until the perito- 
neal wound is healed.” In his case, reported in the American 
Journal of the Medical Sciences, the bowels were moved on the 
sixteenth day. I have found that the earlier and freer evacu- 
ation of the bowels the better for the patient, and, as after lap- 
aratomy, have usually tried to have a free evacuation of the 
bowels on the second day. « 
Shall Forceps or Ligatures he used?—In performing the above 
operation I voluntarily used forceps from the emergency of the 
case, and to save time. At first I clamped the whole broad 
ligament with forceps; but realizing that the projecting end of 
the forceps, by any restless or involuntary movement of the pa- 
tient, might do injury, I thought best to ligature the top of the 
broad ligament and clamp the lower portion. I also saw that 
by using forceps, even with the greatest care, a fold may be 
left in the broad ligament, and possibly one of the numerous 
1 Gynecological Transactions, 1888, p. 177. 
2 Ibid., p. 204. FOR MALIGNANT DISEASE. 
45 
blood vessels may be left insecure. In general I use forceps or 
ligatures, as circumstances make it most convenient. Both are 
needed. Both are equally commended. Forceps many con- 
sider not so reliable and not always to be depended upon ; a 
clamp may give way ; the patient’s life, in the still hours of 
the night, may hang on the security of one little clasp. With 
my fourth and fifth cases the patients were extremely fee- 
ble, and I worked with the expeditious haste of a good many 
forceps. Eighteen forceps were used; they were removed 
twenty hours after; all did well. Some of them were made by 
Tiemann; most of them were Tait’s small forceps. H. T. By- 
ford 1 says: “ I still use ligatures whenever I can do so satisfac- 
torily.” In 1888 I saw Fean deliver a uterus by vaginal hyste- 
rectomy for a small intermural fibroid. The uterus was almost 
as large as the fourth month of pregnancy, lie used many for- 
ceps. When the woman was placed in bed she was not ex- 
pected to live through the night. 
Pozzi states: “If the use of ligatures be possible, it is pre- 
ferable. Forceps pressure has caused laceration and injuries of 
the intestines. They narrow the field of operation and prevent 
proper asepsis by the necrosis of the tissues included.” 
Martin says : “ I am now positive that ligatures can be applied 
as rapidly, if properly understood, and with greater security 
than the forceps.” Krug 2 says: “Any operator with skill can 
tie as quickly as put on the clamp.” E. W. Cushing 9 says: 
“ In any case I think the sutures rather than clamps are indi- 
cated.” Another writer says: “ I always use clamps instead of 
ligatures, not only because thereby the operation is shortened 
and hemorrhage more safely controlled, but because the weight 
of the handles of the clamp insures thorough drainage.” In 
August, 1888, I received a letter from Dr. E. C. Dudley, of 
Chicago, saying: “ I am preparing a paper to be presented at 
the meeting of the American Gynecological Association in Sep- 
tember on ‘ Yaginal Hysterectomy with Hemostasis by Pressure 
Forceps.’ I should like to include your cases in the table of 
statistics. Will you kindly make out a tabulated statement, 
1 Gynecological Transactions, 1888, p. 204. 
3 American Journal of Obstetrics. 
3 Annals of Gynecology, June, 1892, p. 550. 46 
JONES : COLPO-HYSTERECTOMY 
under the enclosed form, of your operations?” I sent him a 
table, of which the following is a portion : 
STATISTICS. 
Date. 
6 
be 
< 
Diagnosis. 
To what extent, if ar all. 
were ligatures or 
sutures used ? 
Remarks. 
Mrs. C., June 
4th, 1887. 
60 
Carcinoma.. 
Ligaturesand sutures; 
no forceps left on. 
Patient able to be up in 
two and a half weeks. 
Very much improved in 
health. 
Mrs. E., Sep- 
tember 18th, 
1887. 
49 
Sarcoma 
A ligature at the top 
of each broad liga- 
ment ; the rest of 
the ligament se- 
cured by forceps. 
Forceps removed in forty- 
two hours. The patient 
was able to leave hospi- 
tal in seventeen days, 
and has, up to this time, 
had excellent health. 
Mrs. N 
37 
Sarcoma 
Do. 
Forceps removed in fifty- 
eight hours. Patient 
much improved by ope- 
ration. No return of 
disease. 
Mrs. H., Oc- 
tober 28th, 
1887. 
49 
Carcinoma.. 
Do. 
Forceps removed in thirty- 
six hours. No return of 
disease. 
Mrs. E., No- 
vember 28th, 
1*87. 
39 
Carcinoma.. 
Do. 
Eighteen forceps removed 
in forty-eight hours. 
Patient able to be out of 
bed on the seventeenth 
day. 
Incisions.—Many of our best operators make a circular in- 
cision around tlie cervix, open into the peritoneal cavity an- 
teriorly and posteriorly, and deliver through Douglas’ cul-de-sac. 
The two openings must give more liability to sepsis, and even 
to malignant infection; for while delivering the fundus the 
cervix is apt to pass, through the second opening, into the peri- 
toneal cavity. In an operation I once witnessed, at one step the 
fundus was exactly in the vaginal canal, obscuring the view and 
impeding the work, while the cancerous cervix was up in the 
peritoneal cavity. What was to prevent infection? E. C. 
Dudley,1 of Chicago, said he “ put absorbent cotton in the 
cervix, in case it did get into the peritoneal cavity.” Is it not 
better to keep it out of the cavity, even though so securely pro- 
1 Gynecological Transactions, 1881, p. 204. FOR MALIGNANT DISEASE. 
47 
tected % Yet, delivering the fundus through Douglas' cul-de-sac, 
it may become a necessity; the uterus has to he turned, and 
cannot always he doubled upon itself. We see, again, that this 
method of delivery is unnatural. It is throwing the uterus as 
much as two-thirds of a circle from its normal position, which 
necessarily makes a great strain on the broad ligaments, the 
nerves, and a dangerous strain upon the bladder and its attach- 
ments, which continued strain may cause rupture in some vessel 
that may result in fatal hemorrhage. James B. Hunter1 stated 
that he “ had a number of times seen hemorrhage result from 
traction on the broad ligaments when there were no adhesions.” 
Our little point will avoid many difficulties here, if, as Joseph 
Price* suggests, “not to perforate anteriorly until the finger is 
hooked over the broad ligament posteriorly and indicates the 
point at which you wish to perforate.” Thomas Keith, in re- 
moving a uterus in 1881, brought down the fundus posteriorly. 
This bringing down the uterus through Douglas’ cul-de-sac is 
not free from danger, and in many respects; besides, there 
are peculiar advantages in delivering anteriorly. Probably in 
no way can the broad ligaments be so easily approached; and 
the entire work of tying them, delivering the uterus, etc., can be 
done before the posterior attachments of the vagina are severed. 
Even if the uterus be displaced or retroverted, it is better first 
to put it in position, as I did in my third case, and proceed by 
anterior delivery. Though in this case the uterus was retro- 
verted, prolapsed, and complicated by an intermural fibroid, yet 
I found it easier to deliver through the anterior incision. The 
posterior delivery, I repeat, is more difficult, accompanied by 
greater possible danger and by greater shock. 
I have become more and more convinced that the method 
I pursued in the last four cases is the one that can be done 
with the greatest ease and celerity, and is attended with the 
least shock and danger. Delivering posteriorly, we, as the 
British Medical Journal3 asserts, “ cut through structures that 
lie in the dark, or at least are difficult of access.” If the ute- 
rus is delivered anteriorly the fundus can be readily brought 
forward, and securing the broad ligaments becomes an easy 
'American Journal of Obstetrics, May, 1887. 
2 Annals of Gynecology, p. 556. 
* Editorial, March 26th, 1887, p. 680. 48 
JONES : COLPO-HYSTERECTOMY 
procedure. One can see all that is to be done, there is room 
to work, no structures are on a dangerous strain, and there is 
no necessity of making numerous stitches. Opening anteriorly 
also enables us to dispense with the many speculums, retractors, 
and other ponderous instruments that are placed in the vagina, 
which really obscure the view and impede the operation. 
Let us for a moment examine the procedure of one of our 
most eminent operators—Martin, of Berlin. He says: “My 
method of vaginal extirpation is as follows: The vault of the 
vagina is exposed by means of a speculum and side pieces. 
The cervix is seized with bullet forceps in its posterior border 
and drawn forward as far as possible toward the symphysis 
pubis. Then I make an incision through the entire extent of the 
insertion of the vagina into the uterus, in order to advance into 
Douglas’ cul-de-sac as quickly as possible. It' the mass of tissue 
to be cut through is very thick, then this penetration will be 
very difficult and troublesome. I enlarge the opening into 
Douglas’ cul-de-sac, then, with a small needle which is very much 
curved, I sew around the entire border of the cut in the vagina, 
usually with live stitches. I force my way deeper and deeper 
along the posterior wall. Next I sew up the stump of the broad 
ligament, for which purpose I use large needles armed with a 
double thread, thrusting them from this vaginal wall toward 
the place in the side of Douglas’ cul-de-sac, while my forefinger 
within presses toward me.” 
All this while the uterus is being held in this forced position, 
with the great strain upon many structures. Martin continues : 
“ I go deeper and deeper along the posterior wall.” Even for 
the most dexterous this is extremely difficult. 
Martin further says: “I cut around the anterior periphery 
while drawing the uterus forcibly backward and putting the 
anterior vaginal wall on the stretch.” Many a bladder will be 
wounded or opened and many an operator come to grief. He 
says: “Drawing the uterus forcibly backward, I push back 
along the cervix with my finger nail that portion of the bladder 
that is united to the cervix, as far as I can discern the attach- 
ment.” This separating the bladder from the cervix is one of 
the nice points of the operation, and, if done with the finger 
nail, the bladder may give way before some of the surrounding 
tissues. Dr. J. B. Etheridge, of Chicago, says: “ It is the easi- 49 
FOR MALIGNANT DISEASE. 
est thing in the world to open into the bladder.” Martin con- 
tinues : “ Not infrequently it is necessary to use a knife in order 
to separate the firmest hands of the uterus. . . . We must sew 
as exactly as possible the separated surface to the vaginal wall. 
Five stitches generally suffice.” 
Now, both anteriorly and posteriorly, the vagina is sepa- 
rated from the cervix. Thus there are two openings into the 
peritoneal cavity. He says: I grasp once more the posterior 
portion of the uterus. I seize its posterior lip with Muzeux 
forceps, in order to draw it firmly forward, and by obtaining 
successively fresh grips on the forceps I guide the posterior wall 
of the cervix and fundus into the opening, delivering poste- 
riorly. If the uterus is large this stage of the operation may be 
made exceedingly tedious. An advantage is often secured by 
pushing the cervix up behind the symphysis pubis. Sometimes 
an instrument is placed into the uterine cavity to push the fun- 
dus down.” But he said: “I like to avoid using this instru- 
ment, because the posterior wall of the uterus is generally bored 
through by it and the contents of the uterus escape on the sur- 
face of the wound. As soon as the fundus of the uterus has 
presented itself it passes through the opening, though in some 
cases this is attended with many difficulties, which must be over- 
come by using the knife or scissors.” 
Martin says: “ The further detachment of the uterus in this 
inverted condition is very difficult. I isolate the insertion of 
the broad ligaments to the organs thus turned out; I tie in the 
nerves and blood vessels.” Is it any wonder if some fine artery 
in the great plexus of blood vessels may be ruptured by this ex- 
cessive strain, and produce a hemorrhage or oozing which it is 
impossible to detect or correct, and that even this master in gyne- 
cological surgery might not be able to prevent ? 
The second patient on whom he operated in the Murdock 
Free Hospital in Boston may have had this accident. The re- 
port, as given in the Annals of Gynecology, says : “ No no- 
table difficulty occurred during the operation, except much hem- 
orrhage from stump of broad ligament after removal of uterus. 
Dr. Martin put in several deep stitches or ligatures, and the 
hemorrhage seemed to be arrested. Patient came out of ether 
well, but sank and died during the night at 4:30 a.m. Autopsy 
showed quarts of fresh blood in the cavity. There had been 50 
JONES : COLPO-IIYSTERECTOMY 
no discharge of blood by the drainage tube, and no particular 
symptoms by which hemorrhage could be differentiated from 
the shock of operation.” 
Dr. Martin continues: “Into Douglas’ cul-de-sac there is 
placed a Sims speculum or a side holder, and this protects the 
fundus from catching on the posterior portion of the wound. 
And if the uterus is large and thick this stage of the operation 
may be made exceedingly tedious, which must be overcome by 
using the knife or scissors. The further detachment of the 
uterus in this inverted condition is very difficult.” 
The report of the case operated on in Dr. H. O. Marcy’s pri- 
vate hospital says: “ Although the vagina was roomy and the 
large uterus was not adherent, yet Dr. Martin found great diffi- 
culty in turning the fundus over into the vagina.” 
Delivering the fundus anteriorly there is no special difficulty. 
It almost slides out on the inclined plane. No speculum or side 
holders have to be introduced to keep it from catching on the 
border of the wound. 
Martin continues : “ I isolate the insertion of the broad liga- 
ment to the organ thus turned over. I tie each side in one, two, 
or three segments, then cut away the uterus. When the cervix 
has been freed from behind and both sides, I enter on the de- 
tachment of the bladder.” No wonder he says : “ Even after 
having done the operation two hundred times I never feel 
quite free from embarrassment at this point. ... I ascertain 
the condition of the bladder by a catheter, and then conclude 
the operation.” 
This would seem to be the first thing to consider. The ob- 
ject should be, not to consider an injury, but to prevent it. Even 
this great operator has cut into the bladder. Of one instance 
he says: “The connection between the uterus and bladder was 
quite extensive, but the opening in the bladder was reduced 
even during the operation by the natural contraction of the 
parts.” But, said he, “as the opening had been difficult I did 
not wish to prolong it by the suture of the bladder. The pa- 
tient recovered and left the house eight weeks after the opera- 
tion with a small opening in the cicatrix of the fundus.” In the 
Other case “ he united the edges of the bladder and the border 
of the peritoneum to the vaginal. The patient left the hospi- 
tal in three weeks, complaining still of some discomfiture in the FOR MALIGNANT DISEASE. 
51 
bladder, which could retain only a small amount of urine. . . . 
The duration of the operation varies, according to the difficul- 
ties, from twenty minutes to two hours.”1 
E. W. Cushing * says of Martin’s operation : “ An amount of 
suturing which to any one less expert would involve a ter- 
ribly long operation, as, in fact, it does.” Wathen, of Louis- 
ville, said of Martin and Schroder, “ their technique was 
faulty.” 
Dr. G. M. Tuttle3 was present at the first operation performed 
by the surgeon who is credited with the largest number of hys- 
terectomies on record, and he was sure that at that time he 
lacked a great deal in the manner. 
Let us for a moment study the methods . of other distin- 
guished operators who have also had great success. Schroder 
says : “ The uterus is pulled down as far as possible, a circu- 
lar incision is then made in healthy tissue around the cervix, 
and the vaginal mucous membrane pushed back and upward. 
Douglas’ pouch is opened by a transverse incision, and the ute- 
rus is then turned over so that its fundus appears at tlieopening. 
[ generally first produce retroflexion and pull the body of the ute- 
rus through the incision in Douglas’ pouch, separate the perito- 
neum of the vesico-uterine pouch, leaving the uterus, attached 
now only to the broad ligaments. These are ligated either with 
a single ligature or in different portions. The wound in the peri- 
toneum is now cleared and the stump of the broad ligaments 
sewed in.” Emmet4 says: “By combined manipulation the 
uterus is now retroverted and an attempt is made to bring the 
fundus through the wound in the peritoneal vaginal vault. 
This is not an easy matter, and the difficulty increases with the 
size of the uterus.” 
When I was in Dresden in the fall of 1886 I saw Leopold 
deliver a cancerous uterus posteriorly ; and of all his operations 
that I had the pleasure of witnessing, this was the most beautiful 
and the most gracefully done. I sat at his left and had an oppor- 
tunity of seeing every step in the procedure. He delivered pos- 
teriorly, as some of our best and most successful surgeons have 
1 Annals of Gynecology. 
3 Obstetrical Society, Philadelphia ; Annals of Gynecology. 
3 New York Obstetrical Society. 
4 “ Principles and Practice of Gynecology,” p. 530. 52 
JONES : COLPO-HYSTERKCTOMY 
done. During the same year I had an opportunity of seeing 
Martin, of Berlin, perform several vaginal hysterectomies. 
In 1881 Dr. C. Fenger, of Chicago, performed a successful 
operation, when for the best operators there was twenty-five per 
cent of deaths. Yet, says lie, “ I did not hesitate, after care- 
ful investigation, to resort to the operation. A circular incision 
was made through the vaginal mucous membrane, so that the 
peritoneal cavity was opened posteriorly. The body of the ute- 
rus was anteverted and drawn out through the anterior cul-de- 
sac.” This came near being an ideal operation. The patient 
did well. Anderson, the first one who did this operation in this 
country, made an incision through the vaginal wall around the 
entire cervix, opened the peritoneum both anteriorly and poste- 
riorly. 
Almost uniformly operators open the peritoneum both ante- 
riorly and posteriorly, retrovert or retroflex the uterus, and de- 
liver through Douglas’ cul-de-sac. 
Duncan, who reported the first cases of vaginal hysterectomy 
to the London Obstetrical Society, cut the vaginal mucous mem- 
brane around the cervix, opened the peritoneum anteriorly, then 
Douglas’ cul-de-sac, and retroverted the uterus. 
Purposes for which Colpo-hysterectomy may be performed.— 
1. For malignant diseases. 2. For small intermural myoma. 
3. For senile atrophy. 4. For otherwise incurable prolapse. 5. 
For intractable inversion of the uterus. 6. For incurable endo- 
metritis. 7. For endometritis hemorrhagica. 8. For uterine 
retroflexion. And finally, in January, 1880, Martin performed 
the operation for a case of retained placenta, when the posterior 
wall of the uterus had become injured. The operation has also 
been recommended for ulceration and inflammation of uterine 
appendages. Pean and Segond advise it in the treatment of 
peri-uterine suppuration. Frank, of Cologne, has performed it 
for uterine diseases that have refused to yield to all other means 
of treatment. lie has done it when he was unable in other ways 
to arrest quickly a uterine hemorrhage seriously jeopardizing 
life. He did it in two cases when the removal of the ovary had 
failed to relieve hysterical troubles, where the patients continued 
to show the most violent hystero-epileptic attacks. Both were 
completely cured by the performance of hysterectomy. 
Richelot said : “ One could readily foresee the time when the FOR MALIGNANT DISEASE. 
53 
field of this operation would be greatly extended.” It may help 
many conditions that seem incurable and that are otherwise 
beyond remedy ; yet the principal scope and object of this ope- 
ration is to comhat malignant disease. But even for this can 
we not find something better, something that is not attended 
with danger and more fully meets all the indications ? Cannot 
something be found that will cure the disease, give no shock, nor 
allow of secondary formations? So fearful is this disease in its 
nature, so destructive in its effects, and so surely fatal in its ter- 
mination, should we not more seriously turn our attention to 
studying it, its etiology, how to prevent, cure, or stay its prog- 
ress ? 
Hewitt 1 has said: “ Cancer of the generative organs is un- 
doubtedly the most formidable affection to which woman is 
liable.” Duncan adds : “ Pain often exceeding in intensity all 
that can be imagined, and all tending surely and swiftly to a 
fatal issue.” Meigs repeated in 1859 : “Little can be done till 
the woman sinks into the grave, her only and her last, best 
refuge.” Two veteran gynecologists of England say: “ I know 
of no means by which the progress of cancer can be arrested” ; 
and when all the profession re-echo the same, is it not time for 
us to look into this most frightful of maladies, study it well, and 
endeavor to save the thousands that are annually destroyed by 
it? We are still more urged to this by recognizing the fact 
that the disease is steadily on the increase. Sir Spencer Wells, 
December 1st, 1S86, said : “ While sanitary science is shortening 
the duration and lowering the fatality of some diseases, cancer- 
ous diseases are more prevalent and more fatal; there is a 
gradual increase in the mortality, greater than the proportional 
increase of population.” The number of deaths from cancer in 
England increased from 7,245 in 1861 to 17,113 in 1887. In 
this country from 1877 to 1887 there were 156,924 deaths from 
cancer. Dr. Fordyce Barker says: “ The mortality from cancer 
in the city of New York has risen from 400 to the million in 
1875 to 530 to the million in 1885.” 
Every year sounds the same notes of rapid increase. Is it 
not our duty as physicians and surgeons to continue still more 
sedulously our studies to find not only the best methods of 
1 British Medical Journal, December 1st, 1888. 54 
.tones: colpo-hysterectomy 
curing, but, if possible, the prevention of tbe disease ? Sir James 
Paget, in his lecture ou cancer and cancerous diseases, November 
11 tli, 1887, says: “ We are bound to seek everywhere and in all 
ways to find a method for either the prevention or cure of 
cancer and cancerous diseases.” 1 John Marshall said, in 188b, 
in the Morton lecture on cancer and cancerous diseases, delivered 
before the Royal College of Surgeons: “We know not the cause. 
But does that prevent us from endeavoring to ascertain the 
cause? Are we not compelled, as members of a scientific pro- 
fession, to dive into its mystery 2 It is likely that Providence 
has, as it were, struck such a fatal blow at the human construc- 
tion that there is no remedy for our ignorance, that there is no 
knowledge but what we may possess. We are responsible for 
carrying on this investigation and inquiring into this disease 
until we know something more about it.” “To this,” say West 
and Duncan, “our common humanity prompts, our obligations 
as medical men compel us.” All feel the necessity of studying 
this most mysterious of diseases ; but it is only by microscopical 
investigation that we can settle these mysteries, or get “light, 
more light still” on these peculiar, painful, and penetrating 
growths. J. Sims Woodliead, Director of Research Laboratory 
of the Royal College of Physicians and Surgeons, says: “ We 
owe to histology and statistics almost all knowledge concerning 
cancer that has been hitherto acquired.” 
In some of my late microscopical researches in the morbid 
anatomy of the ovary, earnestly trying to find out why diseases 
of these organs should destroy the health, comfort, and active 
usefulness of the individual, I came, in December, 1888, to an 
ovary which was a marked specimen of cancerous infiltration. 
I studied it from day to day, and returned repeatedly to the in- 
vestigation of so interesting a subject. In June, 1892, I saw 
clearly that the inflammatory corpuscles of the “small cel- 
lular infiltration ” around the growth were changing to cancer 
epithelia and forming cancer nests.2 This fact is of the greatest 
practical importance, as I have indicated in another part of this 
paper, and heeding it may save the lives of many that otherwise 
would be lost. As early as 1883 Dr. Charles Heitzmann, with his 
clear penetration, suggested that the small cellular infiltration 
1 British Medical Journal, 1887. 
* Medical Record, March 11th, 1893. FOR MALIGNANT DISEASE. 
55 
around a cancerous tumor was “ the first stage of cancer.” But 
here, in this specimen, it was positively proved that this cellular 
infiltration was already cancer and formed a part of the malignant 
growth. 
In studying the same specimen, I also demonstrated that can- 
cer epithelia are conveyed to various parts of the system and to 
distant organs by the lymphatic vessels; and that these vessels 
form, at varying intervals, new cancerous foci and new centres 
of infection. 
That cancer cells should be carried by the lymphatics has 
long been supposed to be the case, because the lymphatic gan- 
glia in the neighborhood of the growth were the first to become 
affected ; but it had never before been seen. This, so far as 
I know, is the first time the lymphatic vessels have heen re- 
cognized, distended with their burden of cancer epithelia and 
carrying the disease germs. The thrombus in the lymph ves- 
sels becomes filled with new living matter, the epithelia grow 
and increase, and the nuclei divide and subdivide. I have 
watched this in repeated instances. J. Marshall, of London, 
says: “ Shall we not hope to unfold the mystery of mysteries 
which lies in the nucleus of a cancer cell? ” 
Under a power of twelve hundred diameters I have seen some of 
the marvellous changes taking place in the cancer nuclei. They 
become coarsely granular, undergo division into smaller pieces 
of protoplasm, or, as some say, there is a “wild evolution of 
cells.” Thus the nuclei break up into a number of irregular 
lumps of living matter, each one becoming an active centre of 
infection. They invade the lining endothelia of the lymph 
vessels. These endothelia become enlarged, filled with granular 
matter, and also undergo karyokinetic division. Changes take 
place iii the wall of the lymph vessels, they melt away, and the 
cancer passes into new fields, taking possession of new and 
larger territories, still growing and spreading. Under the 
microscope the tissues around the lymph vessel were found 
filled with cancer epithelia ; even the fibrous connective tissue 
surrounding the thrombus was in a state of active proliferation. 
What is there in this nucleus that gives it such power to in- 
crease and multiply, and to destroy the natural structure of all 
tissues, and to sap the life of the strongest and most robust per- 
sons ? 56 
JONES : COLPO-HYSTEKECTOMY FOB MALIGNANT DISEASE. 
One author speaks of “cancer juices,” and intimates that 
cancerous growths may be “anarchical”—that is, without the 
controlling nerve tibres. These growths are not anarchical, 
they are still under vital control, and no cancer juice or chemi- 
cal change can elaborate these formations. They are formed by 
the mysterious life principle, and under some morbific element. 
Sir Samuel Paget says: “ I believe that micro-parasites, or sub- 
stances produced by them, will some day be found in essential 
relation with cancer and cancerous diseases.” Many have sup- 
posed they have found the micro-organism of cancer, but the 
discovery still eludes us; the mystery of mysteries still lies 
locked in a cancer nucleus, yet to be discovered in the study of 
structure and of life changes. 
163 De Kalb avenue.