'Cancer oMe Cervix Uteri. 
Treatment by 
***^BPi Amputation. 
BY 
WILLIAM H. BAKER, M.D., 
BOSTON. 
EEPRINT FROM VOL. XVI. 
{^ttecoCogtcar urnnsactions. 
1891. CANCER OF THE CERVIX UTERI. 
RESULT IN ITS TREATMENT 
BY 
HIGH AMPUTATION. 
BY 
WILLIAM H. BAKER, M.D., 
PROFESSOR OF GYNECOLOGY, HARVARD UNIVERSITY 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN GYNECOLOGICAL ASSOCIATION, 
SEPTEMBER, 1891. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1891. CANCER OF THE CERVIX UTERI: 
Result in its Treatment by High Amputation. 
By William H. Bakek, M.D., 
Boston. 
The great importance of the subject, the rapid increase in 
the frequency of the disease, as particularly shown by the 
startling statistics of Sir Spencer Wells, in his lecture before 
the Royal College of Surgeons about two years ago, as well 
as my great personal interest in the subject, is my excuse for 
asking your attention to its further consideration. 
There is perhaps no disease where it is more important to 
trace the future history of the case than that of cancer of the 
uterus. The very life of the patient may depend upon the 
close observance of the affected part for years subsequent to 
an operation for its removal. The rules which shall guide 
us in determining the best course to follow iu our future 
practice can only be wisely decided after a careful considera- 
tion of past cases, a thorough knowledge of their termination 
or present condition having been obtained. The great diffi- 
culties surrounding this work has been the experience of 
many of our Fellows and can be well understood by all. 
Particularly is this the case in a large hospital experience, 
where little is seen or known of the patient except on the 
operating-table, yet here is where our largest experience is to 
be obtained. Pawlik could not trace 22 out of a total of 136 
cases, while among our own number, our honored Byrne 
failed to find 160 of the 367 cases reported in 1889. While 4 
CANCER OF THE CERVIX UTERI. 
the very full report of our late President, Dr. Reamy, in 
1888, showed au inability to trace to completion 10 af the 55 
cases reported. It is then a matter of congratulation that in 
the limited number of cases which I herewith present to the 
Society I can give them in their completeness. This, how- 
ever, was accomplished only by the most persistent labor, 
and necessitated the aid not only of the medical profession, 
but many town clerks, undertakers, police and other city 
officials, and even the public press through most alluring ad- 
vertisements. And I would here take the opportunity to 
thank the various members of the profession, most especially 
Dr. H. C. Baldwin, who have so cordially given their time 
to the observation of many of these cases, being assured that 
the success which has attained in some of them is due in no 
small degree to their early detection of some slight evidence 
of returning disease, while it could be attacked by subsequent 
operation. 
In collecting the statistics of cases where any radical opera- 
tion has been attempted, one is surprised to find what a small 
proportion this class bears to the whole number of cases seen 
or even operated upon by a more or less palliative method for 
symptomatic relief. 
Dr. Clement Cleaveland, in the fourteenth volume of our 
Transactions, referring to his large service in the New York 
Cancer Hospital, says: " The majority of cases of carcinoma 
uteri admitted to the hospital are already well advanced, for 
which the treatment is essentially palliative." 
In the thirteenth volume of our Transactions, in the article 
by Dr. Reamy, reference to which has been already made, 
during the ten years covered by his report, to offset the 55 
cases where the radical operation of high amputation was per- 
formed, were 250 cases, which, when first seen, were too far 
advanced to admit of entertaining any hope from this pro- 
ceduce; and this small proportion of really hopeful cases 
appears to be the experience of all observers. 
In my own report of the first series of cases in 1882, out of WILLIAM H. BAKER. 
5 
47 cases only 12 were found suitable for radical operation; 
and during the seven subsequent years, from 1882 to 1889, 
of the whole number of cases observed, being 92, only 16 
were such as offered any hope from high amputation. 
It is then an interesting question to ask ourselves at the 
start, Why is it that the specialist sees comparatively so few 
cases at a sufficiently early stage of the disease to accomplish 
the most by a radical operation? The answer is twofold. 
First. The early symptoms are not marked; pain, as a 
rule, being absent until late in the progress of the disease; 
and hemorrhage and leucorrhceal discharge are considered by 
the patient as conditions to be expected at the menopause, 
which she supposes is about to take place. 
Secondly. The general practitioner is too frequently inclined 
to delay any radical measures until he has wasted an amount 
of valuable time with useless remedies, which has destroyed 
any hope that might have been entertained for saving the life 
of the patient by a radical operation. 
The first cause arises from ignorance of the patient and 
therefore her failure to consult her physician. Unfortunately 
the ignorance is the more excusable as the early symptoms 
are so ill-defined. It should, therefore, be borne in mind by 
the profession that the physicians are the ones to educate 
women to the idea that the climacteric period is not necessarily 
one of sufferance of all the evils that they have believed, and 
that if hemorrhage occurs, there must be some pathological 
reasons for it, and the same in regard to leucorrhceal dis- 
charges. Thus they will be led to turn to their physician for 
advice when any deviation from the normal condition pre- 
sents itself. In the second cause we have less excuse to offer 
for the ignorance of the physician. If he does not know the 
condition or importance of the diseased state which he finds 
present, he should be honest enough to say so. He should 
consider it his duty carefully to examine every case that pre- 
sents any of the possible rational signs of this disease, not 
alone digitally, but by the aid of the speculum. He should 6 
CANCER OF THE CERVIX UTERI. 
not be content to delay the more thorough examination by 
removing a portion for microscopical examination in any 
doubtful case, satisfied with the idea that a little time will 
determine the true nature of it, or that he will see the effect 
of this or that application to the local disease, or by trying to 
convince himself that he ought not to alarm the patient by 
making so much of her trouble as would be entailed by the 
necessary examination. He should remember that the life of 
the patient is in his hands, and his consideration of her feel- 
ings at this time may be brought up against him later, and 
thus he be justly censured for having failed to offer her the 
means of recovery while it was possible to perform a radical 
operation. 
It is, therefore, necessary that the physician himself should 
have a well-grounded belief iu the good which may result 
from operative interference, else we cannot expect him to 
insist on carrying out the necessary steps to lead the patient 
to such means of relief. With a view of encourao-inv the 
© o 
faithful worker in this field of surgery, as well as awakening 
a spirit of hopefulness in the non-believing physician or sur- 
geon, I have searched for the cases which I reported in 1882 
and subsequently iu 1886, and now am able to give you an 
account of them after nearly ten years from the original 
report. 
At the first report in 1882 there were 10 cases in which 
my operation of high amputation had been performed with- 
out any death from the operation, which included all the 
cases where the said operation was carried out in its entirety, 
out of a total of 47 cases seen during the previous five years. 
This report did not, however, include 2 cases where the com- 
plete operation was not performed, in that after the high 
amputation had been done, the wound was closed with silver 
sutures instead of using the thermo-cautery to the whole de- 
nuded surface, and in which cases the disease returned within 
a few months. It was probably these 2 cases which led me to 
abandon the closing of the wound and the substitution of the WILLIAM H. BAKER. 
7 
open method of treatment after applying the thermo-cautery, 
which application of heat by the cautery I consider of equal 
importance with the thorough removal of the disease, which 
is so strongly insisted upon by Dr. Byrne, and the import- 
ance of which is shown by the excellent results obtained by 
him, and also by Braun, of Vienna.1 Eight of these 10 
cases were living and well at the time of this first report, 
having enjoyed a varying respite from the disease of from a 
few months to four years. At the second report on these 
cases in 1886, 6 of the 10 cases were living and well after a 
varying interval of from four to eight years, the remaining 2 
cases having succumbed to the disease, one after a few months, 
the other after two years. Of this 60 per cent, of cases re- 
ported well after an interval of not less than four years, I 
am now able to report 50 per cent, of the original cases well 
after a period of from ten to twelve years. 
The first case, Mrs. Dwight, known in the report as Dr. 
Morris's case, died October 18, 1886, probably from a return 
of the disease after a respite of eight years. For some time 
there was much uncertainty in regard to the cause of her 
death, as no autopsy was allowed, and in the discussion of 
Dr. Beamy's paper before this society in 1888, I expressed 
the opinion that this patient died of some other disease; but 
on a careful consideration of all the rational signs present, 
both from Dr. Morris, who attended her a few months pre- 
vious to her death, as well as from the account of Dr. Ham- 
mond, of Charlestown, who attended her at the time of her 
death, I think there can be little doubt that she had a return 
of the disease, which caused her death through a recurrent 
peritonitis. 
The second case was that of Mrs. Frost, upon whom I operated 
November 8, 1879, and within a month did a slight secon- 
dary operation with curette and cautery. With the exception 
1 " Malignant Disease of the Uterus," by W. T. Lusk, M.D. American Sys- 
tem of Gynecology, page 632. 8 
CANCER OF THE CERVIX UTERI. 
of suffering dysmenorrhoea from the very small channel left 
by the contraction of the cicatrix, she has been perfectly well 
since. Two years ago she began to menstruate at long inter- 
vals, and now, at fifty-four years of age, that process has 
ceased. I made a careful examination of her both digitally 
and with the speculum July 16, 1891, nearly twelve years 
from the time of her operation, and found no evidence of any 
return of the disease-in fact, she is in perfect health. 
The third case was that of Mrs. Davis, referred to me by Dr. 
S. W. Langmaid. She was operated upon January 31, 1880, 
and again June 30th of the same year. She was a widow at 
the time of her operation, but married again some five or six 
years ago, and it was with great difficulty that I was able to 
find her. I examined her May 19, 1891, and found her per- 
fectly well. I doubt if a more hale aud hearty looking woman 
of sixty-six years of age can be found. It is now nearly twelve 
years since the first operation, and there is little or no uterus 
to be felt, the vagina ending in a blind pouch. 
The fourth case was that of Mrs. Adams, referred to the 
Free Hospital for Women, by Dr. Belt, of South Boston, 
who had diagnosticated cancer of the cervix at the birth of 
her last child, three months previous to my seeing her. The 
diagnosis was subsequently confirmed by the microscopical 
examination, which was made in all the cases reported. Her 
operation was performed October 7, 1880, and within two 
months I was obliged to use the curette and cautery again to 
destroy a slight cropping out of the disease. Since this time 
she has enjoyed good health. She is now forty-seven years 
of age, and is still menstruating, She has for some years 
past filled the position of matron of one of the largest of our 
public institutions of Boston. I examined her May 4, 1891, 
and found her entirely free from any evidence of disease. It 
will thus be seen that she has had a respite of nearly eleven 
years. 
The fifth case was that of Mrs. Haines, referred to me by 
Dr. E. H. Stevens, of Cambridge. I operated upon her at WILLIAM H. BAKER. 
9 
the Free Hospital for Women, May 24, 1881, and during 
the subsequent three years she was operated upon four times 
for some suspicious-looking out-growth at or near the original 
wound : the first time by Dr. Stevens, the next two times by 
Dr. F. H. Davenport, and the last time by myself. I made 
a careful examination of her April 23, 1891, and found her 
perfectly well. She is now matron of one of the city insti- 
tutions of Cambridge, enjoying good health over ten years 
from the date of her first operation. 
The sixth case was that of Mrs. France, referred to the 
Free Hospital for Women by Dr. Cox, of Holyoke, Mass. 
She wras operated upon January 26, 1882, aud within four 
months I was obliged to cut through the cicatrix to let out a 
collection of retained menstrual flux, this being the only in- 
stance in my experience where this has become necessary as a 
result of the cicatricial retraction following the operation. 
She was most carefully examined with the speculum April 
14, 1891, by Dr. Julia M. Patten, of Holyoke, who reported 
her entirely free from any return of the disease, and saying, 
" She has increased much in weight of late, presenting a most 
robust appearance." In a letter received from her recently 
she reports her in good condition, although no speculum ex- 
amination of her was made at that time. Thus nearly ten 
years has elapsed since her operation. 
The summary of this first series of cases shows 50 per cent, 
of them well from ten to twelve years after the date of the 
operation. 
The real success of any operation for cancer of the cervix 
uteri can only be determined by the length of respite from 
the recurrence of the disease, and this can only be ascertained 
by the greatest care and patience in the following up of cases, 
and in learning their exact condition for years afterward. To 
the family physician, who lives and grows old with three 
generations, this may seem an easy matter, but to the special- 
ist in extensive hospital and consultation practice it is a most 
difficult, painstaking, and oftentimes impossible undertaking. 10 
CANCER OF THE CERVIX UTERI. 
Contrary to the opinion of many authorities, it is a matter 
of the most vital importance which method of procedure we 
adopt in cases of this class, and the fact that our operation has 
removed all the disease which to the eye or touch was present, 
is not by any means a safeguard against its rapid recurrence. 
In fighting such a destructive disease, that knows no limita- 
tion of human structure, we should call to our aid every sense 
that can help us to make sure of its complete eradication, and 
having removed all the portions which to the eye or touch 
seem infiltrated, leaving only healthy tissue behind (said ope- 
ration to be done with scissors and knife), we are then to 
make doubly sure of the result by the most thorough cauteri- 
zation of the whole surface-going over and ovei' the denuded 
portion until it presents a veritably black, charred face. 
I have not found in my experience the objection to the first 
part of this operation made by .our honored Fellow, Dr. Byrne. 
He says on page 97 of the fourteenth volume of our Trans- 
actions : " If ordinary cutting instruments, such as scissors or 
scalpel, be first used to remove diseased parts, it will rarely 
be possible to proceed with the final and by far the most 
essential part of the operation-that is cauterization, as it 
ought to be done-without subjecting the patient to a second 
ordeal for this special purpose. Plunging any actual cautery 
instrument into a mass of bleeding or otherwise wet tissue, 
will certainly fall far short of the desired object." Now I 
fully and most heartily agree with him in regard to the im- 
portance of the thorough use of the cautery; but I cannot 
give up the use of scissors or scalpel in first removing all the 
disease possible. Neither can I give up the aid of the sight 
and touch in bringing about this object, as I should do if I 
made use of the cautery from the beginning. As a matter of 
fact, a great part of the success in the first part of my opera- 
tion, or that of dissecting out the supra-vaginal cervix, which, 
as we all know, is the part where we are most likely to have 
troublesome hemorrhage, depends upon the prevention or im- 
mediate arrest of such hemorrhage, thus enabling us to pro- WILLIAM H. BAKER. 
11 
ceed with a clean wound. For if the vagina is repeatedly 
and rapidly filling with blood, we shall do our work only 
imperfectly. Firm traction on the cervix will do much to 
prevent troublesome bleeding, but many times it becomes 
necessary to carry a stout, twisted silver ligature through each 
lateral vaginal vault so as to include the main uterine artery ; 
after which we can generally proceed as with an ordinary 
dissection. The advantage of the silver ligature is that, as 
the operation proceeds, the shrinking of the tissues makes the 
ligatures loose, and bleeding again takes place. By an extra 
twist or two of the ligature, seized close to the bifurcation of 
the wire, we at once have it under control. This it may be 
necessary to do two or three times during the operation. 
Then again when we come to the second part of the opera- 
tion, or the substitution of the cautery, we can apply the in- 
strument without any fear of severing our ligature. I would 
not be understood by this to depreciate in any sense the im- 
portance of the thorough use of the cautery, for I am in most 
hearty accord with Dr. Byrne in considering this part of the 
operation perhaps the most important as a safeguard against 
future recurrence of the disease. We cannot be too thorough 
in working against the inroads of such a terrible disease. 
If I might be allowed to criticise so admirable a paper, 
supported by such remarkable results, as that of our ex- 
president, Dr. Beamy, which I do with great diffidence as I 
may not correctly understand his method of operating, it 
would be this, that he depended more upon the cautery to 
meet the necessities of the case in subsequent recurrence of 
this disease, rather than as a part of the original operation. 
In this opinion I may be mistaken, but in carefully reading 
his paper, together with his remarks on Dr. Byrne's paper 
the following year, I am impressed with this fact. I quote 
from the discussion of Dr. Byrne's paper, page 105, vol. xiv. 
Dr. Beamy says : " But if the disease be not all removed, it 
will as certainly return after the cautery as after other meth- 
ods. It is the thorough removal of the local disease that 12 
CANCER OF THE CERVIX UTERI. 
assures the cure in an encouraging number of cases, and the 
method by which removal is accomplished is of but little 
moment, so it be safe. For my own part, for reasons given 
in a publication already before the profession, I prefer in 
many cases the scissors to the cautery." 
To this I should reply, Why prefer either? why not make 
use of both as a part of each operation? The best results that 
have been yet obtained have followed the use of the cautery; 
and evidently the effect of the heat of this agent at a red glow 
cooks the tissues-if I may be allowed the expression-beyond 
where the scissors or knife have penetrated, and thus has a 
peculiarly destructive effect upon the tissues invaded by the 
disease. It is true that this may be unnecessary in a certain 
small number of cases, but we cannot tell in advance which are 
the cases which will require it most, and it is best to be as sure 
as possible from the beginning. To emphasize this point I 
would refer to the sixth case in the series just reported, in 
which, although I cut freely and to all appearances was outside 
of the disease and in healthy structures, and should have con- 
sidered it a case which more than most could be safely left 
without the use of the cautery, yet from continued practice, as 
well as from my firm belief in the efficacy of the cautery, I 
fortunately followed out the usual steps of my operation. I 
say fortunately, for, as the subsequent microscopical examina- 
tion of the cut surface of the part removed showed, the dis- 
ease extended on all sides beyond the parts removed; and 
thus it would seem certain that, had it not been for the 
destruction of so much more of the remaining tissues, the 
disease would have quickly returned. By its use ten years 
have intervened without any present evidence of return. 
Let us consider now the second series of cases, which in- 
clude all those in which I performed high amputation, from 
January 26, 1882, to same date, 1889. I have not carried the 
series further because the multiplication of statistics in these 
cases is only misleading, if success is claimed when operated 
upon within two or three years. WILLIAM H. BAKER. 
13 
Case I.-Mrs. G. C. was referred to me by Dr. A. B. Briggs, 
of Ashaway, R. I., March 13, 1882. She was forty years of age, 
had given birth to two children, and had suffered no miscarriages. 
She had an old laceration of cervix, and the cancer had evidently 
developed from it, nearly filling the upper vagina. There was 
no history of hemorrhage other than a gradually increasing 
menorrhagia; offensive leucorrhoea for over a year; pain not 
marked. March 21st, operation. Dr. Briggs had the subsequent 
care of the case; recovery good. Disease recurred in a little 
more than two years, and secondary operation was done with 
curette and cautery. Finally, disease recurred in anterior 
vaginal wall, and she died February 19, 1885. 
Case II.-Mrs. J. L., of Worcester, Mass., was admitted to 
the Free Hospital for Women, May 13, 1882. She was thirty- 
four years of age, had two children, and no abortion; health 
good up to eight months before; history, severe hemorrhage and 
offensive leucorrhoeal discharge; no pain ; large mushroom-like 
mass of disease sprouting from a lacerated cervix. May 14,1882, 
operation; recovery good; patient discharged from the hospital 
June 24th. 
This case was not seen again, but I ascertained from the 
city clerk that her certificate of death was signed, " peritonitis 
and cancer of the uterus," and dated June 4, 1888. This 
patient, dying six years after the operation, shows the im- 
portance of keeping all cases of this class under observation 
for many more years than is generally thought necessary. 
Case III.-Mrs. B. B., of Blackstone, R. I., consulted me 
early in December, 1882. She was fifty-three years of age, and 
had been married twice; first marriage at nineteen years of age, 
and the second at twenty-one; had no children; no miscarriages; 
menopause at forty-three; six months before began to flow again ; 
nearly constant slight flow of blood, rather than any severe and 
exhausting hemorrhage; some offensive leucorrhoeal discharge; 
pain in the back a marked symptom, not affected by position of 
body. Operation December 7, 1882. The disease here was of 
the cervical form, and the ulcerative process had nearly kept 
pace with the infiltration. It was therefore with great difficulty 14 
CANCER OF THE CERVIX UTERI. 
that the supra-vaginal cervix was dissected out, so friable was its 
structure. The uterus, however, was movable. Recovered well, 
and returned home in a month from the time of the operation. 
She was seen at varying intervals afterward for a time, but, 
changing her residence, I lost track of the case until about two 
years ago. In a letter from her husband dated Lewiston, Idaho, 
April 23,1891, he reports her in perfect health, saying: " Since 
she arrived in this city about four years ago, she has not had any 
use for a physician, and has neither called on one, nor had one call 
on her. Plenty of physicians here, and plenty for them to do 
outside of my family." She has thus enjoyed a respite of more 
than eight years. 
Case IV.-Mrs. J. G., a resident of Boston, consulted me 
June 20, 1883. She was forty-four years of age, and had been 
married nineteen years; no children; four miscarriages at the 
third to fourth month, during early years of married life; health 
good until two years before; for one year immediately before, 
menstruation excessive and anticipated by a few days; some 
leucorrhoeal discharge, non-offensive ; pain in right groin, extend- 
ing down thigh, and in right breast, at times severe; entire cervix 
involved in the disease; vagina or cellular tissue about supra- 
vaginal cervix not involved. Operation June 23,1883 ; recovered 
well. Within following year secondary operation with scissors, 
curette, and cautery ; for about four years had fairly good health, 
followed by symptoms of nephritis. She died December 29,1889, 
of interstitial nephritis. 
I am indebted to Dr. V. Y. Bowditch for the opportunity 
of seeing and examining carefully this patient a few days 
before her death, and I found not the slightest evidence of any 
return of the disease. Thus she had no recurrence of cancer 
in six and one-half years; dying of some other disease after 
that length of time. 
Case V.-Mrs. F. P. W., of North Brookfield, Mass., was 
referred to the Free Hospital for Women by Dr. Francis Minot, 
February 22, 1884. She was forty years of age; had been mar- 
ried twenty-three years ; one child, and no abortion ; was operated 
upon in the Worcester Hospital five months before; complains WILLIAM H. BAKER. 
15 
of copious offensive leucorrhceal discharges, at times bloody; 
severe pain in right hip and back; no severe hemorrhages, 
neither excessive menstrual flow. Operation March 6,1884; re- 
covered somewhat slowly; was obliged to apply chloride of zinc 
to suspicious-looking points; returned to the hospital after six 
months for secondary operation with curette and cautery; 
enjoyed good health until the summer of 1889 ; had a stroke of 
apoplexy, followed by paralysis of one side of the body; never 
fully recovered; died November 3, 1890. 
For this statement I am indebted to her husband, as a 
letter addressed to Dr. Warren Tyler, the physician in attend- 
ance at the time of her death, was returned to me with the 
account of Dr. Tyler's death within a few months from that 
of his patient. She then lived nearly six years without any 
return of the disease, and died from an independent affection. 
Case VI.-Mrs. H. J. B. was referred to me by Dr. L. F. 
Osman, of Boston, March 5, 1884. Forty-three years of age; 
married eighteen years, and gave birth to four children ; three 
abortions; considered herself well until seven months before; 
suffered from dragging, bearing-down pains, and soreness in 
lower abdomen; no sharp pain; constant bloody discharge 
between menstrual periods for seven months; no severe hemor- 
rhage ; no excessive menstrual flow. Operation March 7,1884 ; 
recovered well; subsequently cared for by Dr. Osman; no sec- 
ondary operations allowed ; disease quickly recurred in the uterus 
and extended to the left ovary; the patient died November 10, 
1884. 
She thus died from recurrence of the disease within eight 
months from the time of her operation. 
Case VII.-Mrs. W. E. was referred to me October 20, 1884, 
by Dr. J. L. Wells, of Boston. Fifty-six years of age; married 
thirty years; one child, and no miscarriages; menopause at 
fifty; slight discharge of blood at three different times during 
past two months; some offensive leucorrhoea; pain complained 
of in legs and feet for two years, and in upper left thigh more 
recently; entire cervix involved, and infiltration invading left 
vaginal wall, impairing mobility of the uterus on that side. 16 
CANCER OF THE CERVIX UTERI. 
Operation November 4, 1884. By carrying a large, broad liga- 
ment needle far out toward left pelvic wall and securing a 
twisted silver ligature, the blood-supply was so thoroughly cut off 
that I was enabled to carry the dissection well out into the 
broad ligament, as well as the lateral vagina, in addition to doing 
the usual high amputation of the cervix. She recovered well, 
and within five months I was obliged to perform a second opera- 
tion with scissors, curette, and cautery. From this time on, the 
patient has enjoyed good health and is now well, it being nearly 
seven years from the date of her first operation. 
In a letter received from Dr. Wells a few months since, he 
says : " In answer to your questions I would say that your 
patient has had no hemorrhages, no leucorrhoea, no vesical 
symptoms for years. Has gained fifteen pounds since leaving 
the hospital, and her general health is very good." Here is a 
case which seemed almost hopeless from the start, yet by 
carefully carrying out each step of the operation, and attacking 
the disease again on its reappearance, her life has been saved 
and she is still well after nearly seven years. 
Case VIII.-Mrs. A. S., of Providence, R. I., was referred to 
me by Drs. Carr and Porter, of that city, October 29, 1884. 
Twenty-seven years of age; married ten years; two children; 
no abortion; complained of a copious, offensive leucorrhoea for 
two years; continuous hemorrhage for four months, requiring 
two or three napkins a day; pain in back and sides since flow 
began, characterized as severe, though not enough to keep her 
awake. Operation November 7,1884; recovered well; no second- 
ary operation. September 27, 1890, Dr. G. W. Porter, of Provi- 
dence, made a speculum examination of this patient, and reported 
her entirely free from any local return of the disease, and in 
good health. August 15, 1891, he reports her well. Thus she 
is still enjoying a respite from the disease after nearly seven 
years. 
Case IX.-I was kindly asked to operate upon Mrs. C. A. M., 
of Providence, R. I., by my esteemed friend, Dr. G. W. Porter, 
of that city, who expressed a desire to follow the steps of my WILLIAM H. BAKER. 
17 
operation. Patient thirty-six years of age; married seventeen 
years; four children; no abortions; no severe symptoms com- 
plained of; some leucorrhoea, backache, and pain in the groins ; 
disease involved the entire cervix, and encroached somewhat on 
the posterior vaginal wall. Operation January 27, 1885; re- 
covered well; no secondary operation. 
I saw this patient but once afterward, which was April 14, 
1885, at which time there was no evidence of any recurrence 
of the disease. Dr. Porter took all the subsequent care of 
the case, following it up closely from time to time. In 
answer to a letter of inquiry as to her condition, he wrote 
me September 27, 1890, that he had recently examined her 
with the speculum and found her free from any return of the 
disease and in good general health. A second communica- 
tion, February, 1891, reports her still well. Thus, after 
nearly six years, there is no evidence of any return of the 
disease. 
Case X.-G. H. was admitted to the Free Hospital for Women 
in February, 1885. Thirty-four years of age; marriage ques- 
tionable ; one child; an abortion six months before entrance to 
hospital; for two months severe hemorrhages; lost strength 
rapidly; no leucorrhoeal discharge; pain not marked; whole of 
cervix involved; disease nearly filled the vagina. Operation 
March 5, 1885. On account of the poor quality of the silver- 
wire ligatures, which kept breaking, the second part of the 
operation, or the cauterization, was only imperfectly carried out; 
and subsequently, when the specimen was examined microscop- 
ically and the disease still found present on the left side of the 
cut surface, I felt it necessary to make another attempt to remove 
more of the disease. This I did April 7th, by attempting to 
ream out another portion from the body of the uterus, guided 
by the point of the sound kept at the fundus. But this was a 
difficult undertaking, inasmuch as the usual landmark of the 
cervix was gone, and I found that I had cut quite through the 
side of the uterus. Nor do such disasters come singly, as I dis- 
covered, on removing the sponge-holder, that the sponge had 
2 18 
CANCER OF THE CERVIX UTERI. 
been left in the peritoneal cavity. This, together with the smart 
hemorrhage which was going on, made it look rather dubious for 
a few moments. By the aid of the hand of my assistant crowd- 
ing the parts well down into the pelvis from above, I was able 
to touch the sponge through the rent in the uterus and thus seize 
it with forceps and remove it. It was then the work of but a 
moment or two to pass the sutures through the wall of the uterus 
from within, thus bringing the surfaces of the rent together, which 
effectually controlled the hemorrhage. I was then able to dry 
the parts well and apply the thermo-cautery. This patient was 
making a good recovery, and was able soon to be about the ward. 
She suddenly left the hospital against my advice, and died five 
months afterward near Portland, Me., with all the rational signs 
of a return of the disease. 
This case well illustrates the difficulties of cutting out a 
second cone from the body of the uterus when the usual 
landmarks are gone: also the trials sometimes to be met in 
following the results of operations, for her after-history was 
only learned by repeated and alluring advertisements in the 
daily papers. 
Case XI.-Mrs. F. H., of Westford, Mass., was referred to 
me by Dr. J. B. Heald, March 20, 1886. Forty years of age; 
married eighteen years; three children; no abortions; had always 
been well until within seven months; complained of severe hem- 
orrhages at intervals of one or two weeks; no special pain; no 
offensive leucorrhoea. Three months before Dr. Heald operated 
for removal of the disease with scissors and galvano-cautery; was 
still a small portion of the infra-vaginal cervix left, deeply in- 
filtrated with the disease, also each lateral portion of the vagina; 
uterus fixed; altogether not a hopeful case upon which to do 
any radical operation. Operated March 22, 1886; recovered 
well; secondary operation with scissors, curette, and cautery 
twenty months afterward; disease recurred again, and patient 
died July 2, 1888, a little more than two years from the date of 
first operation. WILLIAM H. BAKER. 
19 
Dr. AV. J. Sleeper, under whose care she was at time of 
death, writes me: " There was secondary growth of some 
nature, evidently connected with the ovary." 
Case XII.-Mrs. S. R., of Waltham, Mass., was referred to 
me by Dr. Willis, of that city, November 29, 1886. Fifty-one 
years of age ; married thirty years ; two children ; no abortions; 
menopause at forty-eight; after cessation of three years, began 
to flow again nine months previous; flow constant thereafter; 
no severe hemorrhage; no offensive leucorrhcea ; no pain. Opera- 
tion December 1,1886 ; recovered well; no secondary operation. 
The after-treatment of the case was entirely in the hands of Dr. 
Willis, who watched her most carefully for any evidence of 
returning disease, but such never appeared. She died in August, 
1888, from exhaustion occasioned by mental disorder. In answer 
to a letter addressed to Dr. 'Willis, he says: " There was no local 
return of the disease. There was no secondary growth. A few 
months before her death her mind became affected, there was 
great loss of flesh, and she died from complete exhaustion." 
Case XIII.-Mrs. K., of Corinth, Vt., was referred to me by 
Dr. O. AV. Doe, in May, 1888. Forty-four years of age; married 
nineteen years; two children; two abortions; severe hemorrhage 
and some leucorrhoeal discharge occasionally mixed with blood ; 
very little pain. Operation May 24,1888 ; subsequently two sec- 
ondary operations with scissors, curette, and cautery; recovered 
well from both. August 21,1891,1 examined her carefully with 
the speculum, and found her perfectly well. Thus a respite of 
more than three years has been gained for her. 
Case XIV.-Mrs. F. A. S., of Boston, consulted me October 
27, 1887. Thirty-eight years of age; married sixteen years; 
two children; no abortion; for four or five months previously 
complained of irregular hemorrhage, though not severe; no 
offensive leucorrhcea; no severe pain. Operated November 7, 
1889, assisted by Dr. E. J. Forster, of Charlestown; recovered 
slowly, but -well; recurrence of disease within six months; 
treated with chloride of zinc; died November 28, 1888, in one 
year from the time of operation. 
Case XV.-Miss M. was referred to me by Dr. A. D. Sinclair, 
October 31, 1888. Forty-seven years of age; had always 20 
CANCER OF THE CERVIX UTERI. 
enjoyed good health until within a year; menstrual flow then 
became too frequent and lasted too long, continuing slightly 
throughout the month; some offensive leucorrhoea; sharp shoot- 
ing pains in region of rectum and in lower abdomen ; examina- 
tion showed ulcerative process had already destroyed about one- 
third of infra-vaginal cervix. Operation November 1, 1888; 
recovered well; no secondary operation. February 22, 1891, I 
examined her carefully with the speculum, and found no evidence 
of any return of the disease. The vagina now ends in a blind 
pouch. She has never menstruated since the operation, neither 
has she any of the symptoms of such process. Thus she has had 
a respite of three years. 
Case XVI.-Mrs. C. L. S. was referred to me by Dr. Cham- 
berlain, of Lawrence, Mass., in January, 1889. Fifty-four years 
of age ; been a widow for twenty years; three children; one mis- 
carriage ; menopause at fifty-one; about two months before com- 
plained of some thin leucorrhoea, somewhat offensive, and at 
times bloody; no severe hemorrhage; pain the prominent 
symptom, existing in left groin and hip, beginning at same time 
as discharge; entire cervix involved in the disease. Operation 
February 16, 1889. In dissecting out the supra-vaginal cervix 
the disease encroached so closely on the bladder-wall that a por- 
tion of that viscus was removed, and subsequently the opening 
closed. She recovered well, and no secondary operation was 
necessary. Repeated examinations failed to discover anything 
but a healthy appearance. I examined her carefully with spec- 
ulum in May, 1891, and have since heard from her of her con- 
tinued good health. Thus she has enjoyed a respite of nearly 
three years. 
The case of Mrs. Cole, of Attleboro, Mass., has not been 
included in this list, as I was not allowed to complete the 
operation. She had been reduced to the last degree by hemor- 
rhages, following a severe attack of diphtheria a few months 
before, and there was much question whether she could endure 
the shock of the operation. While dissecting out the supra- 
vaginal cervix, her immediate condition became the cause of 
great anxiety, although there was no hemorrhage to warrant WILLIAM H. BAKER. 
21 
such fear. The physicians in charge desired me to discontinue 
the completion of the full operation. Thus a case which 
promised at the start to be favorable for a radical operation 
was changed to a palliative one, as all the disease was not 
removed, neither the cautery used. She died from the disease 
in about two weeks from the time of the attempted operation. 
As this was the only case in my experience which had suc- 
cumbed to the disease within a short time of an attempted 
operation, I thought best to report it in this connection, 
although I could not see any good evidence to consider her 
death caused immediately by the said operation. 
In analyzing seven years' work in this operation, from 1882 
to 1888, we find there were 16 cases in none of which did death 
occur from the immediate effect of the operation. In 10 of 
these 16 there was no return of the disease; 1 was well after 
8 years, 2 after 7 years, 3 after 6 years, 3 after 3 years, and 1 
after 2 years. Thus there was no evidence of any recurrence 
of the disease in 62J per cent, of the cases operated upon. Of 
the 10 cases where there was no recurrence, 3 died of some 
independent disease, viz. : 1 died of interstitial nephritis, 1 of 
paralysis following apoplexy, and 1 of mental disease. There 
are then living to-day, after a varying interval of from three 
to eight years, 53^ per cent, of the remaining cases. Of the 
16 cases, 6 died from a recurrence of the disease; of these, 1 
lived 6 years, 1 lived 2| years, 1 lived 2 years, 1 lived 1 year, 
1 lived 8 months, and 1 lived 5 months 
The claims then that I would make for this operation are : 
First, greater safety to the life of the patient; second, longer 
respite from any recurrence of the disease. In support of 
these claims it is with pride that I ref^r to the years of work 
of our honored president, both as a skilled operator in its 
performance, and as contributing to our literature monographs 
in which preeminence is given to this operation over the more 
dangerous one of vaginal hysterectomy. Nor must I forget 
to refer to the most sincere and conscientious work of our 
secretary in this operation, as evidenced in his admirable 22 
CANCER OF THE CERVIX UTERI. 
paper before the New York Obstetrical Society a little more 
than a year ago, in which, as a result of his large experience 
at the New York Cancer Hospital, he strongly advocated high 
amputation in all cases of cancer of the cervix. 
The want of success of some operators in this field must 
result either from a lack of realization of the thoroughness 
which is necessary in the work of removal, cutting well out- 
side of all the disease and in healthy tissue; or else from 
their becoming confused by the hemorrhage, and not having 
a knowledge of the ready means of its control ; or still again, 
from the non-recognition of the importance which the thor- 
ough use of the cautery has in the destruction of still more of 
the tissues on the border-line of the diseased part. 
Much may be gained in some cases, even though the dis- 
ease has extended beyond the cervix to the anterior or pos- 
terior vaginal w'alls, necessitating the opening of the bladder 
or the peritoneal cavity. The dangers of the operation are 
but little increased even though the peritoneal cavity or the 
bladder be entered, and a portion of the upper vagina removed 
with the cervix, provided the opening be closed with silver 
sutures, and the cautery applied. Nor should we be discour- 
aged, even though the disease has extended somewhat laterally, 
and thus interfered with the free mobility of the uterus, as was 
instanced by Cases VII. and XI. of the second series. 
Too short a period of time is generally accepted as a 
standard of respite from recurrence of the disease, upon which 
to base statistics. From the fact that one case, in the first 
series reported, died from the disease eight years after the 
operation, and that another, in the second series, had a recur- 
rence, to which she succumbed after six years, the great import- 
ance is shown of keeping all of these cases under observation 
for many years. 
A study of the foregoing would seem to indicate : 
First: That a thorough removal of all the disease should 
first be made with scissors, scalpel, or uterotome, keeping well 
outside the infiltration, and apparently in healthy tissue. WILLIAM H. BAKER. 
23 
Second : That the wound should not be immediately closed, 
but that every portion of it should be kept under observation 
until entirely healed. 
Third : That the thorough application of the cautery is an 
all-important factor in the success of this operation. 
Fourth : That it is often necessary to do some slight sec- 
ondary operation to insure success. 
Fifth : That the cases must be under close observation for 
years. 
Sixth : That the collecting of statistics of operations based 
upon a respite of eighteen months or two years is of little 
value, except to show the mortality of any particular opera- 
tion, or to show in what percentage of cases the disease recurs 
within that time. 
As a result of my experience with this operation as well as 
with vaginal hysterectomy, I would present the following : 
First: That in all cases of cancer of the cervix which have 
not become fixed by an extension of the disease, high amputa- 
tion, with the application of the cautery immediately follow- 
ing, is the safest and best method of treatment. 
Second : That vaginal hysterectomy should be reserved for 
cases of cancer primarily affecting the corpus uteri, or those 
exceedingly rare eases of cancer of the cervix where the dis- 
ease has extended to the entire corpus without fixing the 
uterus. 
DISCUSSION. 
Dr. John Byrne, of Brooklyn.-It is hardly necessary for me 
to say that I have listened with great pleasure and much satis- 
faction to the able paper of my friend, Dr. Baker. It bears the 
evidence of careful observation and a large experience in a field 
which, it is to be regretted, has, up to the present time, had few 
laborers. My views with regard to the treatment of cancer of 
the cervix uteri, and the results obtained by my method of 
operating, are already matters of record. Therefore I might 
content myself by merely welcoming this additional evidence 24 
CANCER OF THE CERVIX UTERI. 
brought forward to-day in favor of the position which I have 
occupied on this question for over twenty years. But there is 
one point, at least, to which I must refer and claim your in- 
dulgence, and that is the operative proceedure to wrhich the term 
''high amputation" is applied, regardless of its limits. 
I have already stated before this Society and elsewhere that 
high amputation in the hands of an expert operator, so far as 
the removal of diseased uterine tissue is concerned, can be more 
thoroughly accomplished, and with greater safety, by the delicate 
platinum knife, such as I am in the habit of using and which I 
now exhibit, than by scalpel, scissors, or any other means. 
I have, then, not only no difficulty in effecting by galvano- 
cautery what is, at least, equivalent to the highest possible ampu- 
tation, but, in addition to the avoidance of hemorrhage-in 
itself no small matter-the action of the cauterizing agent, the 
most potent germicide, on outlying structures is such that 
neither immediate sepsis nor traumatic infection can possibly 
occur. These are clinical facts which the advocates of other 
methods cannot fail to appreciate, and which, in my opinion, 
cannot much longer continue to be ignored or treated with in- 
difference when we are confronted with the question as to a 
choice of methods. 
There is, however, such widespread misconception regarding 
the thoroughness with which a cancerous uterus may be treated 
by galvano-cautery, and comparatively so little known as to the 
proper manner of conducting such operations, that the following 
brief excerpt from the history of a patient operated upon July 
7, 1871 (published in 1872), may be of interest in connection 
with the discussion of Dr. Baker's timely and welcome paper: 
" The cervix having been removed, the platinum knife (curved) 
was now applied to the deeper tissues beyond, wThich were cau- 
tiously sliced off, piece by piece, laterally as well as upwrard, to 
the utmost extent deemed safe. When the uterus w'as thus 
scooped out, a bell-shaped cavity was left, which from the bottom 
to the fundus uteri measured but half an inch." 
This patient is now living and well after twenty years, and is 
known to another Fellow7 of this Society, who was present at the 
operation. DISCUSSION. 
25 
In further illustration of my method, I would submit the fol- 
lowing from one of my cases operated upon in 1875 and pub- 
lished in 1877: 
"An expanding double tenaculum (the instrument here 
shown) was passed well up the cervical canal, and when opened 
the uterus was so firmly held that any degree of traction could 
be steadily maintained. A circular fissure close up to the 
vaginal insertion was next made for the reception of the plati- 
num loop, the cautery knife being directed obliquely upward 
and inward. The wire being now adjusted and firm traction 
kept up, the loop was contracted at proper intervals (tightening 
the slack merely) until the part embraced was severed. A sharp 
curette was next passed within the uterine cavity and the latter 
was thoroughly scraped out. Sufficient space having thus been 
made for another electrode, but having a larger cauterizing area, 
the interior was gone over so as to remove or destroy all softened 
and diseased tissues with which it might come in contact. The 
cavity was now sponged out carefully, and a tampon soaked in 
acetic acid and tannin applied for a few minutes, so as to pre- 
pare the part for the next, and perhaps the most important, step 
of the operation. A dome-shaped cautery instrument, brought 
to a cherry-red heat, was now applied to the excavation in every 
part, and, when withdrawn, the cavity was sponged and dried, 
and again cauterized until the parts were completely charred 
and black." 
I may state that I have occasionally modified the proceeding 
just described by continuing the dissection of the cervix from 
the bladder, rectum and lateral connections, as in vaginal hys- 
terectomy, and completing the amputation with the cautery knife 
instead of the loop. It is also proper to remark that, in my 
report of 1889, the patient whose case I have just referred to 
was included in the list of those who could be traced but for a 
short time only, subsequent to the operation, and belonged to 
class II., consisting of cases in which the entire cervix was 
involved. She turned up unexpectedly about six weeks ago, 
calling to consult me regarding suspiciously indurated sub- 
maxillary glands, but a careful examination of her pelvic organs 26 
CANCER OF THE CERVIX UTERI. 
failed to discover any evidence of disease. The period of im- 
munity in her case is, therefore, sixteen years. 
The same course was followed in a similar and apparently 
hopeless case in which I operated for the late Dr. J. Marion 
Sims, and at which Dr. H. Marion Sims assisted. She w'as per- 
fectly well fifteen years after the operation. 
My object in calling attention to these cases is, first, to show 
that the line of clinical investigation undertaken by me over 
twenty years ago has been ably supplemented by Dr. Baker's 
present and former contributions, as well as by Dr. Beamy's work 
in the same direction; secondly, in order that, while discussing 
this important subject, the two methods of procedure, that of 
the author of the paper and my own, may be conjointly and 
carefully weighed and estimated; and lastly, to emphasize what 
has been repeatedly demonstrated, namely, that by the adoption 
of either method and the abandonment of hysterectomy for 
cancer of the cervix uteri as a dangerous and unwarrantable 
mutilation the best results may be obtained and no lives sacri- 
ficed. [I have just been informed that the battery and instru- 
ments, such as I have used, may be obtained from Messrs. 
Kerstan & Kaysan, of Brooklyn.] 
Dr. Thad. A. Beamy, of Cincinnati.-I suppose there are 
gentlemen here who believe nothing that has been said during 
this discussion; who do not believe in anything which has been 
taught, and who have no patience with and no respect for the 
surgeon who, in modern times, -would attempt what they call a 
" patchy " operation for cancer of the uterus. A conservative 
operation is a timid operation-anything short of total extirpa- 
tion of the uterus is, according to them, " old fogy." I judge this 
to be the fact because at the last meeting but one of the American 
Medical Association that position was taken by a class of men 
skilled in debate, ready in speech, with numerous cases to report. 
One of the most earnest debaters on that occasion, as well as one 
of the most talented young men, when pressed in debate, said im- 
patiently at the close of some remarks which I had made: " We 
expect no countenance, no encouragement from any man over 
fifty years old in total extirpation of the uterus for cancer." 
I refer to this to show the spirit which characterized that dis- DISCUSSION. 
27 
cussion, and which characterizes the discussions on this subject 
in various medical societies, and pervades the literature of the 
subject in certain quarters-gives color to it, in fact constitutes 
it, so that a man who dares advocate high amputation for cervical 
cancer must encounter that sort of argument. It is no argument 
at all-simply denunciation. 
These gentlemen advocate removal of the entire uterus simply 
on the ground that the larger the amount of the woman's 
anatomy removed by the surgeon, the stronger the evidence of 
his possessing advanced ideas and surgical courage. 
I want to ask you who are present, no matter on what side you 
stand, what answer can be made to the statistics which have been 
presented in the paper just read? Does anyone doubt the 
truth or accuracy of the history of the cases? Does anyone 
doubt the diagnosis? Does anyone doubt that the treatment 
instituted in these cases was as stated ? Does anyone doubt the 
results secured? This clinical testimony is valid. Dr. Baker has 
concealed no essential facts, nor has he done any padding. 
Now, what answer can be made when we find some sixty per 
cent, of cures in the list of cases presented ? What clinical de- 
fence can be made for substituting total extirpation of the uterus 
in this class of cases? I have carefully examined statistics; I 
have cautiously, honestly, and earnestly studied them, as I have 
seen them reported in the proceedings of the Chicago, New York, 
Philadelphia, and other societies throughout this country and in 
Europe. I know of no record which will bear scrutiny or an 
examination such as science demands, which surpasses this pre- 
sented by Dr. Baker. You may say that he has not reported 
two or three hundred cases. But he has cited a sufficient num- 
ber, and in a way that teaches more than one hundred or five 
hundred cases could teach us if they were presented in a hap- 
hazard, incomplete manner, as they are often reported in medical 
literature. 
The author of the paper was correct when he understood me 
to say that I used the cautery in my earlier operations of this 
character more for the purpose of avoiding recurrence of the 
disease than for the primary condition. He is partly right and 
partly wrong, but in the main right. I did not then, and I do 28 
CANCER OF THE CERVIX UTERI. 
not now, use the cautery where it is perfectly clear that the dis- 
ease is confined at the time of the operation to the portio vagi- 
nalis. When the disease has commenced in the vicinity of the 
os, and has not gone beyond the cervical canal (of course, such 
cases are not very numerous, although several of mine were at 
that stage), I did not then, and I do not now, use the cautery in 
those cases; I use the scissors only. I make a swallow-tail 
amputation and close the wound with silver wire with a view of 
primary union; first, because I believe that the results will be 
better, as there is less damage to the tissue, there is not left such 
an amount of cicatricial tissue, and (on the principle that injuries 
sometimes give rise, to cancer) there is less favorable basis for the 
development of the disease; secondly, because when these cases 
are so treated there is left a better conformation of the parts, the 
deformity being much less than if the cautery had been used 
extensively. 
The author is correct in stating that in most cases, according 
to the report to which he has done me the honor to refer, I used 
the cautery only for recurrence of the disease. Profiting by the 
example of our master in this particular operation, and by the 
example of that other master who has given such a wonderful 
report after the use of the cautery exclusively, I now in all cases 
in which the disease is not confined to the portio vaginalis 
cauterize at the time of the primary operation. 
One word with reference to the value of the method practised 
by the distinguished speaker, Dr. Byrne, who has just taken his 
seat. We all know perfectly well that in the use of the cautery 
in the treatment of disease no man in the country surpasses this 
gentleman in the ingenuity and skill which he brings to its 
execution. At the same time, those of us who are not so skilled 
with the cautery likewise know that it is extremely difficult, 
ordinarily, to get dry tissue. The effect of applying the cautery 
to almost any tissue is the immediate outflow of blood. The 
reason why I use the scissors before using the cautery, and tie 
the vessels farther out even than in vaginal hysterectomy, is 
that I can arrest the hemorrhage, and I can cut as close up to 
the ligature as I please and have little loss of blood. Then, the 
hemorrhage having been arrested, I use the cautery. I clear DISCUSSION. 
29 
away all the diseased tissue which I can discover before cauter- 
izing. I am not skilful with the cautery to a degree that I 
am able, in a reasonable time, to avoid hemorrhage which the 
cautery itself will produce from the smaller vessels, as well as 
the outpouring of blood which may take place from larger 
ones. This is no criticism of the method which the gentleman 
describes, but an apology for myself, who am unable to get such 
good results from primary use of the cautery. 
Now, what are the objects of a surgical operation for the cure 
of cancer of the uterus ? Of course, there underlies this opera- 
tion, here as elsewhere, the idea that in a certain per cent, of 
cases cancer is local; and if local, and it is thoroughly removed, 
it is for that patient, at least for a reasonable time, eradicated. 
We freely grant that in cases where the disease has extended to 
the body of the uterus, and not too far, hysterectomy is indicated; 
also in primary cancer of the body and in sarcoma. Yet where 
it has been confined to the cervix and the uterus has been 
removed, when recurrence takes place it takes place in most 
instances not between the folds of the broad ligament, but in 
different directions from behind the upper portion of the vagina, 
or laterally in this region. Since the disease recurs, therefore, 
generally in this locality, manifestly this is the field where re- 
moval should be most thorough. I submit that this thoroughness 
can be far more certain when only the cervix and outlying tissue 
are removed. We can remove all disease and close the wound 
all the more safely without disturbing the corpus uteri. 
Those who have not mastered high amputation, and have 
taken a fancy for total extirpation, although they have performed 
it but a few times, seem to be impressed with the idea that it is 
the more brilliant procedure, and that the more tissue they 
have taken out the more likely have they removed the pos- 
sibility of recurrence of the disease. The truth is that the more 
thoroughly they have removed the diseased tissue about the 
cervix, and safely gone into sound tissue adjacent to it, the more 
thoroughly have they eradicated the disease. To do high ampu- 
tation well requires large experience in the operation. No one 
can perform total extirpation, tie the vessels and place the lig- 
atures as far out posteriorly and laterally, use his scissors, or his 30 
CANCER OF THE CERVIX UTERI. 
scalpel, or cautery, as thoroughly, dissect out as far from the dis- 
ease in all directions, as in performing high amputation. That is 
the point which I wish to make. Those gentlemen who condemn 
high amputation ignore the statistics on the subject furnished by 
those who do have success with it-a success which comes of 
their belief in the method. In an operation not disturbing the 
pelvic roof, after cutting away with scissors, the field is far more 
exposed and easy of access by cautery. In bad cases I tie or 
clamp farther out from the cervical line in high amputation than 
I have seen anyone do in total extirpation. 
Now, gentlemen, in conclusion, I wish simply to reiterate the 
statement that those of us who have had some success in high 
amputation, and have practised it extensively, have become en- 
thusiastic over it. Our statistics have not been equalled by other 
methods. Our successes have not been equalled. I have seen 
more than one uterus presented at medical societies as having 
been removed for sarcoma, in which there was nothing but an 
endometritis. It was claimed, however, that the operation had 
been radical, and, therefore, that the patient had been cured. A 
distinguished German scientist, Saurenbaus {Zeitschr.fur Geburts- 
hulfe und Gyndlcologie), states that he has examined fifty uteri 
which were the seat of malignant disease, and he found that the 
disease was confined to the portio vaginalis in twenty-one, the 
cervix being involved in twenty-eight. He was unable to find 
any evidence of sarcomatous degeneration of the corporeal endo- 
metrium, or, in fact, any evidence of malignant change in the 
corpus, in a single case. The microscopic appearances were those 
seen in ordinary hyperplastic endometritis, spindle cells being 
uniformly present, but always in the vicinity of the hypertrophied 
glands. It becomes embarrassing when gentlemen show us these 
microscopical appearances and want to convince us that the bril- 
liant operation of entire removal of the uterus has been justified 
by the pathological appearances, and that because of this radical 
operation the woman has been saved a recurrence of the disease. 
If you eliminate from their cases those in which the disease was 
confined to the cervix, you will find that the statistics will be 
turned upside-down. DISCUSSION. 
31 
Dr. Joseph E. Janvrin, of New York.-The operation of 
Dr. Baker and Dr. Byrne must be limited to cases in which 
there is every presumption, after a most careful examination not 
only of the cervix but of the interior of the uterus as well, that 
the disease is limited to the cervix. This preliminary examina- 
tion must, it seems to me, include the microscopic examination 
not only of a portion of the cervix, but also, in many cases, of 
deep curettings from the cavity of the uterus. In many cases 
of apparent disease of the cervix only we find, by this micro- 
scopical examination, that the lining of the body is also in- 
volved, even when the ordinary physical examination does not 
indicate it. 
There is a proper field for high amputation, most certainly, and 
the brilliant work of Drs. Baker and Byrne in that line has done 
much toward establishing it upon so sure a footing that no one 
can afford to pass it by lightly. Such results as both of these 
gentlemen have obtained is wonderful-the more so when we 
look at the rapid advance of this dread disease when, after any 
operation, if a nidus is left, recurrence is sure to take place. 
I take it that the proper selection of cases, cases in which this 
disease has not invaded the body to any extent, and in which it 
is practically confined to the cervix, together with the most thor- 
ough removal of all diseased tissue and the destruction of as 
much surrounding tissue as is possible, are the factors in their 
success. Therefore, to my mind, this operation is to be made use 
of in a limited field only, and the question before us is this: Is 
it the best operation in this class of cases ? That is a question 
which at the present time, I think, cannot be answered either 
affirmatively or negatively, and for this reason : The statistics of 
vaginal hysterectomy for this class of cases are not yet gathered. 
It will probably be years before they can be eliminated from 
the general statistics of vaginal hysterectomy. Until that is 
done it is unfair to both sides of the question to be too much 
influenced by the statistics presented by Dr. Baker. Now as to 
the cases in which vaginal hysterectomy is justifiable. It certainly 
is in all cases in which there is good ground to believe the body 
as well as the cervix is involved. Also in all cases in which the 
body alone is involved, provided in both of these classes that the 
disease does not involve the adnexa or surrounding tissues. 32 
CANCER OF THE CERVIX UTERI. 
The class of cases presented by Drs. Baker and Byrne, to my 
mind, is a class which as yet is to a great extent sub judice as far 
as the election of an operation is concerned. I am frank to 
acknowledge that, in my own work, I am at present doing 
vaginal hysterectomy, and my results are as follows: 
My own cases of vaginal hysterectomy have been limited to 
those in w7hich the cervix alone, or the body alone, or the 
cervix and body alone were involved; in which the vagina was 
absolutely free from disease, as was also the adnexa of the uterus. 
I have operated on twelve such cases, with ten recoveries from 
the operation and two deaths. The first and the ninth cases 
proved fatal. The operations extend as far back as five years. 
I have not gathered the statistics as to the ultimate results, but 
intend to, for the only fair way to decide the value of vaginal 
hysterectomy as an elective operation in these cases is to gather 
the statistics after some years and compare them carefully with 
those obtained by Drs. Baker and Byrne and others who operate 
as they do. 
Dr. W. Gill Wylie, of New York.-My remarks will not 
differ materially from those of Dr. Janvrin. I had some experi- 
ence with what was practically high amputation "when associated 
with Dr. Sims some years ago. I have at times used the cautery, 
but usually employed the zinc paste. I must say that some of 
my cases treated in that manner were very successful. In one 
instance the patient had no return of the disease after sixteen 
years, while other members of the family died of it. One woman, 
operated upon eleven years ago, the cervix being amputated high 
above the disease, remains well to-day, while two sisters and her 
mother have died of cancer. 
I did not take kindly to hysterectomy at first, having become 
attached to high amputation, but about five years ago I became 
convinced that total removal could be practised without great 
risk, and then began to do it. Since then I have operated on 
twenty-five cases, only one death following the removal of the 
uterus. In that instance there proved to be chronic Bright's 
disease, an acute attack being lighted up by the ether. The post- 
mortem showed the ureters free, and that the kidney affection was DISCUSSION. 
33 
the sole cause of death. It seems to me now that vaginal hyster- 
ectomy cannot be classed among the very dangerous operations. 
It is not much more dangerous than high amputation performed 
as thoroughly as Drs. Baker and Byrne recommend. 
In choosing between the two operations, the only argument 
which has been advanced worthy of consideration, it seems to me, 
is that in hysterectomy there is likelihood of not going far enough 
laterally through fear of involving the ureters. The only source of 
danger in going as far as one might desire in doing hysterectomy 
consists in the possibility of including the ureter in the ligature; 
for that reason I sometimes use zinc to extend the destruction 
laterally. 
I am convinced that we must come to the conclusion that a 
radical operation is better than one by which a part of the uterus 
is allowed to remain. I would just as soon to-day take out a part 
of the uterus for cancer and leave the rest, as take out part of the 
breast and leave the rest, and vice versa. I think that the final 
result would be the same in both cases. General surgeons in 
removing the cancerous breast take great pains to remove the 
entire gland, and not only that, but they also remove the glands 
and tissues by which the disease is liable to extend. While 
it is true that the cancerous disease is more likely to return at 
the side of the cervix, yet it is certainly true also, that a return 
of the disease is favored by leaving a portion of the degenerated 
organ in which it made its first appearance. That fact seems to 
me so plain that, wheQ taken into consideration with the slight 
danger of the operation, the choice must in time be that of radical 
removal. Dr. Baker himself admits that opening the peritoneum 
adds very little, if any, real danger to the operation. Of course, 
a great deal depends on the skill and experience of the operator, 
but in the hands of the skilled I would always advocate the 
radical operation. 
Again, one may think he can exclude disease of the body of 
the uterus, but in practice it is a very difficult thing to do. I 
have adopted a rule applicable to all cases, which I think has 
contributed much to my almost uniform success. It consists in 
always putting the patient under ether, cutting or scraping away 
all necrosed cancerous tissue; and in that way I do almost as 
3 34 
CANCER OF THE CERVIX UTERI. 
complete an operation as high amputation, before resorting to 
hysterectomy. That tissue is carefully examined under the 
microscope. By first removing all dead and septic material, the 
final operation is rendered much less likely to cause infection. 
The steps of the operation are, first, get rid of all septic material, 
so that there will be no infection from dead tissue; next, to tie 
the bloodvessels, then to cut away all the tissues it is intended 
to remove, and after having completed the operation as it is or- 
dinarily understood, to trim the tissues as much as it is safe to do 
without involving the ureters or other important structures. 
Then replace fresh ligatures on the stump, which will prove 
almost a certain preventive of slipping and hemorrhage. Then 
pack a piece of gauze against the peritoneum and upper por- 
tion of the vagina, a second piece in the vagina, and a third 
piece in the vulva. The third piece should be changed daily 
and kept perfectly clean. The middle piece is changed if there 
is any odor; but the third piece is not touched for a week or ten 
days. Since adopting these simple procedures, I think I can do 
hysterectomy in suitable cases without much more risk than 
attends amputation of the cervix. 
Dr. Henry T. Byford, of Chicago.-I have performed va- 
ginal hysterectomy twenty-five times, with one death from de- 
lirium tremens. I scrape off the septic material beforehand. I 
have found three or four ounces of pus in the uterine cavity; 
have had the uterus break to pieces and let septic matter out 
while operating, yet the patients got well. I think the operation 
is about as safe as high amputation. I cannot see why, when 
you do hysterectomy, you cannot tie fully as far out and secure 
as wide destruction of tissue as when you use the cautery in high 
amputation. Therefore, it seems to me, the assertion that high 
amputation is safer, because enabling one to remove more tissue 
in a particular location than he could do during hysterectomy, 
is entirely unfounded. 
Dr. Thomas Addis Emmet, of New York.-In a large 
number of cases, when the surgeon is first consulted, very little 
more can be done than to prolong life somewhat by operative 
procedure. Where a patient can be seen early enough, and the 
disease is confined chiefly to the cervix, there is no doubt in my DISCUSSION. 
35 
mind that the high amputation has advantages over removing 
the uterus itself. Entire extirpation of the uterus does not 
appeal to me at all as an advisable operation except in some 
cases of sarcoma. For the ordinary forms of malignant dis- 
ease, as epithelioma confined to the cervix, I am sure I can 
do as radical an operation by the high operation as by any other 
procedure. I learned to do this operation first in a primitive 
manner when assisting Dr. Sims over thirty years ago-when it 
consisted in taking out a cone-shaped piece of the uterus, be- 
ginning at the vaginal junction, then using the cautery or caustic 
to destroy as much tissue as possible, leaving the surface to 
heal by granulation. Dr. Sims operated with the uterus in situ; 
the hemorrhage was excessive, and the operation was not a satis- 
factory one. I had so much trouble in looking after his cases 
from secondary hemorrhage, occurring on the third or fourth day 
or night after the operation, and from the early return of the 
disease, that I was led to pursue a different course. I believe 
that I was the first operator to do the high operation in a radical 
manner. I pulled the uterus down to the vaginal outlet by 
gentle traction, and dissected it loose from the vaginal junction 
until I came nearly up to the peritoneum, and had separated the 
uterus, if necessary, to the same extent from the bladder. I 
then began to excavate the uterine tissues in a cone-shaped mass. 
The traction made was sufficient to roll out the sides of the 
cavity, and as soon as an artery -was divided it was at once caught 
up with a tenaculum. One portion after another of the uterine 
tissue can thus be removed until, if necessary, pretty much the 
whole uterus but the subperitoneal covering can be taken away. 
The dragging down of the uterus in this operation, as in other 
operations about this organ, is a very important procedure, and 
should be understood; for, if it be done properly, the operation 
can be made almost a bloodless one. As we draw down the 
uterus to the vaginal outlet, the arteries are put sufficiently on 
the stretch to lessen the amount of blood circulating, and con- 
sequently there will be less bleeding. It has to be done by steady 
traction, and not by jerking, for some vessel may be torn ; while 
it is not to be attempted if the uterus be fixed from infiltration, 
nor will any operative procedure for removing the uterus be 36 
CANCER OF THE CERVIX UT&RI. 
advisable under these circumstances. It is necessary that a 
divided artery in erectile tissue should be secured at once with a 
tenaculum and traction made until the coats have had time to 
retract, or the loss of blood will be much greater in a given 
time than would be the case if it were situated elsewhere. 
With a fair experience in plastic surgery, I do not take kindly 
to the use of caustics or the cautery when I can do the work as 
thoroughly with the scissors'. I can remove as much of the 
uterus in this manner as can be done by the cautery or otherwise. 
I have not the histories of my cases to enable me to compare the 
results with those obtained by the cautery, but my conviction 
is that they have been as satisfactory in regard to the return of 
the disease, while it seems to me more surgical if one can get 
equally well into healthy tissue; to close in the surfaces to 
heal by the first intention, and not by granulation, we must 
obtain tissues of a higher grade of vitality. But this may not 
be an important point, and therefore let the operator use the 
cautery if he thinks best; but I am satisfied that with the 
scissors I can remove as much tissue with safety, short of punc- 
turing the peritoneum, as can be done by any other means. 
I referred yesterday indirectly to the value of well-directed 
traction when speaking of post-partum hemorrhage, but evi- 
dently was not understood. It struck me that it was better to 
invert the uterus than to resort to Porro's operation, as was 
suggested during the discussion. By inverting the organ you 
can certainly bring traction upon the vessels and control the 
hemorrhage. I have adopted this course in a case of fibroid 
tumor, where the hemorrhage was great, by inverting the uterus, 
and after the tumor had been removed the inversion was re- 
duced. Dr. Howard, now present, witnessed such an operation 
done by me several years ago in the Woman's Hospital. 
I have nothing to say against removal of the whole uterus 
where it is necessary. Where the disease has extended to the 
vaginal tissue on either one side or the other, in my experience 
it is usually more advanced in the cul-de-sac back of the uterus. 
When this is the case, we can dissect off the uterus up to the 
peritoneum, and then take away all the diseased tissue. I have 
taken out half of the cul-de-sac, and then have removed what DISCUSSION. 
37 
could of the uterus by the high method, bringing the parts 
together afterward with silver sutures, and getting union by first 
intention throughout. 
The longest case of exemption in my experience, so far as I 
know, was in a patient who went fourteen years, and then was 
lost sight of. Four and five years have been quite common. As 
far as my observation has gone in cases in which the whole uterus 
has been removed the results have not been so good. 
Dr. Baker (closing the discussion).-I thank the Fellows very 
much for the interest which they have shown in the paper, and not 
to take up too much of your time I shall make my reply to the 
discussion brief. In just such cases as Dr. Janvrin has described 
as appropriate for hysterectomy-cases in which the disease is 
confined to the cervix and the lining membrane of the body- 
we would, I think, gain most by high amputation and subsequent 
cauterization. In such cases Dr. Byrne and I have obtained the 
best results. So far as comparison of the statistics of hysterectomy 
and high amputation is concerned, the advantage is in favor of 
high amputation. I am quite in accord with Dr. Janvrin when 
he says that where the corpus uteri is deeply involved, together 
with the cervix, the proper operation is vaginal hysterectomy. 
But how can you tell in advance ? When we begin to cut out 
the cone-shaped piece from the corpus uteri, the appearance will 
inform us whether we have gone deeply enough at our first step. 
If, then, we find that the disease has involved the deeper struc- 
tures of the uterine body, we may perform vaginal hyster- 
ectomy. Should the outer portion of the cut surface appear 
healthy, it is immediately to be charred with the cautery. 
The question of safety between the two operations is on the side 
of high amputation. At any rate, for the profession in general, 
I think it may be affirmed that high amputation is the safer 
procedure, however it may be with the expert in the practice of 
hysterectomy. As to my own experience with hysterectomy in 
those cases in which the disease primarily affected the body of 
the uterus, eight in number, all the patients recovered. 
In reply to Dr. Wylie. He says he learned to do this operation 
-high amputation-with Dr. Sims. But Dr. Emmet has just 
told us that the operation which Dr. Sims did was very different 38 
CANCER OF THE CERVIX UTERI. 
from that referred to in these cases. Dr. Sims made the base 
of the cone removed at the vaginal insertion, the apex being 
carried up to the os internum, thus removing a portion of the 
supra-vaginal cervix. But high amputation, as it is understood 
in the operation I have described and as Dr. Emmet has stated, 
includes dissecting out the supra-vaginal cervix, drawing down 
and separating the bladder in front and the peritoneum behind 
up to the level of the os internum; then cutting out a cone- 
shaped piece from the body of the uterus, the base of which is 
at the os internum, and the apex at the fundus of the uterus. 
By this operation much more of the uterus is removed than 
by the Sims method, and this is a very important part when we 
remember that cancer is likely to affect the whole of the supra- 
vaginal cervix, and then go on to involve the cellular tissue 
around the cervix and the vagina before it implicates the body. 
I think with Dr. Byrne that it is the subsequent cauterization 
which insures the success of the operation, and I believe that 
those who favor so strongly vaginal hysterectomy will obtain 
greater success with the operation if they will devise some safe 
way of applying the cautery to the denuded surface. 
I agree fully with Dr. Emmet that he can remove almost the 
entire uterus by high amputation; but who can tell in advance 
whether we have not on the cut surface left just a border line 
of the disease ? In that case the cautery would meet an all- 
important indication.