VAGINAL HYSTERECTOMY. 
THE ACTUAL STATUS OF THE OPERATION AND REPORT OF 
FOUR CASES. 
By Christian Hisnoisr, m. d., 
PROFESSOR OF CLINICAL SURGERY IN THE COLLEGE OF PHYSICIANS AND SURGEONS OF CHICAGO; 
SURGEON FOR COOK COUNTY AND EMERGENCY HOSPITALS. 
[From The Medical Journal and Examiner, of November, 1887.] VAGINAL HYSTERECTOMY. 
THE ACTUAL STATUS OF THE OPERATION AND REPORT 
OF FOUR CASES. 
By Christian Fenger. m. d., 
PROFESSOR OF CLINICAL SURGERY IN THE COLLEGE OF PHYSICIANS AND SURGEONS OF CHICAGO; 
SURGEON FOR COOK COUNTY AND EMERGENCY HOSPITAL. 
[From The Medical Journal and Examiner, of November, 1887.] 
IN the short space of eight years, 
1 since 1879, when Czerny, Billroth, 
Schroder and Mikulicz revived vagi- 
nal hysterectomy, a large number of 
operations, probably nearly 500, have 
been performed, and a considerable 
amount of literature on this subject has 
been brought forth. In spite of ad- 
verse criticism, and the apparent gravity 
of the operation, it has had a more 
thorough and general trial than could 
have been expected in so short a time, 
and for an operation attended by the 
uncertainty as to results which pertains 
to all operations for malignant tumors. 
Modern surgery, with its allowance 
of more radical and wider lines for the 
operations for the removal of sarcomas 
and carcinomas, has generally procured 
a larger percentage of definite cures for 
these tumors in all parts of the body. 
Although a percentage of between ten 
and twenty permanent cures seems 
small, yet it holds out a distinct ray of 
hope as compared with inevitable death 
on the side of non-interference-a ray 
strong enough to cause operations of 
this kind to be kept up, even if the 
immediate risk to life is considerable. 
This immediate mortality, however, 
must be within certain limits to permit 
of the general adoption of an operation. 
Freund's abdominal hysterectomy, with 
its mortality of seventy per centum, 
was too grave even for malignant 
tumors. Vaginal hysterectomy, with 
an initial mortality of about thirty per 
centum, was not so grave as to prevent 
the general adoption of the operation. 
But even this mortality has been one of 
the main arguments advanced from the 
beginning against the practicability of 
the operation. It is therefore an im- 
portant question to ask: Has vaginal 
hysterectomy become less dangerous 
since its revival by Czerny in 1879? 
The mortality from the operation for 
the first five years, up to 1884, has 
been stated by Mun de to be twenty- 
eight per centum. In a paper read be- 2 
fore the American Gynaecological As- 
sociation in 1884, he tabulated all the 
cases to be found in the literature both 
in Europe and the United States. The 
number of operations was two hundred 
and fifty-five, with seventy-two deaths. 
For the operations of 1885, recorded 
in Virchow's Jahresbericht 1886, the 
mortality is already much lower. I 
find reports from thirty-two operators 
of one hundred and six cases, with 
seventeen deaths, or sixteen per centum. 
R. Martin reports, in his work of 1887, 
sixty-six cases with eleven deaths, or 
sixteen per centum. Special reports 
from individual operators in the past 
year show even more favorable re- 
sults. Thus we find reported by Klotz 
seventeen cases, with no deaths, and 
by T. Gaillard Thomas fifteen cases, 
with no deaths. Most valuable, how- 
ever, from the large number of cases, 
are the recent reports of Fritsch and 
Leopold. Fritsch reports sixty cases, 
with seven deaths, or eleven and two- 
thirds per centum, and Leopold forty- 
eight cases, with three deaths, or six 
and one-quarter per centum. The re- 
ports from the last operators include all 
their operations from 1883 to 1887. 
Leopold's mortality of six and one- 
quarter per centum is the lowest on 
record for a large number of cases. 
In the beginning of his work in this 
line, every operator has undoubtedly 
operated in cases which were too far 
advanced for reasonable hope of eradi- 
cation of the disease. The more recent 
the origin of the tumor, and, conse- 
quently, the more limited the extent of 
the growth, the better are the immedi- 
ate, as well as the remote, prospects for 
the patient. If, then, in future, the 
cases for operation are properly se- 
lected, we may expect that the mor- 
tality will reach a reasonably low figure. 
I think we must agree with Fritsch in 
his statement that he has " no doubt 
that in the near future the mortality in 
general will come down to three or four 
per centum." 
It certainly seems remarkable and 
far surpassing all expectations that, in 
less than ten years after the re-intro- 
duction of this operation in surgery, its 
mortality should have come down to 
almost the same point as that from 
laparotomy for ovarian tumors. Ovariot- 
omy required a much longer series of 
years to attain the point of safety 
which it has now gained. Vaginal 
hysterectomy for carcinoma may now 
be said to be not more dangerous than 
the extirpation of a carcinomatous 
mamma, with removal of the axillary 
glands, for which operation Billroth in 
1880 gave a mortality of ten per centum, 
a per centage still further reduced, as 
shown by Schmidt, from Kiister's ser- 
vice in the Augusta Hospital in Berlin, 
to five and two-tenths per centum. 
The partial operation of low or high 
vaginal amputation of the cervix has 
been urged as a substitute for vaginal 
hysterectomy in all cases of carcinoma 
of the vaginal portion, and the more 
limited cases of carcinoma of the cervix. 
The former operation is said to be much 
less dangerous than the latter. We 
must then ask the question : Are 
partial operations on the carcinomatous 
uterus, provided they permit of the 
effective removal of the tumor, prefer- 
able, as being much less dangerous than 
the operation of total extirpation? 
Pawlick reports a large series of 
galvano-caustic operations from Braun's 
clinic in Vienna; one hundred and thirty- 
seven cases, with ten deaths-that is, 
seven and one-third per centum. In 
twelve of the cases of recovery late 
hasmorrhages of a severe character 
were observed. Schroder reports one 
hundred and thirty-six amputations of 
the vaginal portion and cervix, with ten 
deaths from sepsis-that is, seven and 
two-fifths per centum. Wallace reports 
ten cases with two deaths, or twenty 
per centum. Gusserow has had thirty- 
three cases, with three deaths, or nine 
per centum. 
We may thus conclude that if the 
mortality of total hysterectomy is in the 
neighborhood of ten per centum the 3 
operation is not much more dangerous 
than the partial vaginal operation, and 
agree with Schatz,, who wrote in 1883: 
"The danger of the high vaginal ampu- 
tation does not seem to be much smaller 
than that of the total extirpation." 
A much larger field than hitherto 
will undoubtedly be accorded in future 
to vaginal hysterectomy. It is in many 
cases almost impossible to determine, 
during the operation, how far up into 
the wall of the uterus the carcinoma- 
tous tissue extends. Even with a mor- 
tality of twenty-five per centum from 
total extirpation, Gusserow, in doubt- 
ful cases, prefers this to the partial 
operations. In this connection he states: 
" The safer the total extirpation be- 
comes, the more will it take the place 
of amputation of the cervix." 
The experience in a very compli- 
cated case of Binswanger is of import- 
ance in our choice of operation. He 
found a perfectly isolated portio-car- 
cinoma, accompanied by an also iso- 
lated carcinomatous degeneration of 
the mucous membrane of the fundus. 
It is generally accepted as a law in 
surgery of the mammary gland that, 
however localized, a small carcinoma- 
tous nodule may be, nothing less than 
the removal of the entire gland,-and 
I think it safe to add, the lymphatics of 
the axilla,-would be the safe oper- 
ative procedure to adopt. It can thus 
be understood that authors who believe 
in a low mortality for vaginal hyster- 
ectomy, as Sanger, Leopold, Fritsch, 
require this operation to be done in all 
cases of limited carcinomas, even small 
carcinomas of the vaginal portion, to 
the exclusion of any of the partial 
operations. Fritsch calls attention to 
the fact that a strict line of demarka- 
tion, between carcinoma of the cervix 
and of the vaginal portion, as described 
by Ruge and Veit in their classical 
article on "Uterine Carcinomas," does 
not exist in all cases. Some apparent 
portio-carcinomas extend deeply up into 
the cervix. It is often impossible, dur- 
ing a partial operation, to determine 
whether we operate in healthy tissue or 
not; consequently, in the majority of 
such cases, total extirpation is safer as a 
radical cure of the carcinoma than par- 
tial operation. 
Indications.-It is important to de- 
termine in a given case whether a car- 
cinoma can be operated upon with 
success, or if it should be let alone. 
Cancerous invasion of any of the tissues 
surrounding the uterus is a contra-indi- 
cation for an operation. Especially 
important is the mobility of the organ. 
Impaired mobility usually means inva- 
sion of the broad ligaments, and to 
this class belong most of the cases in 
which the operation has had either to 
be abandoned or has been exceedingly 
difficult and dangerous, and been fol- 
lowed by speedy relapse in loco. If 
the uterus is not fairly movable, the 
technical difficulties of the extirpation 
are well-nigh insurmountable. At the 
same time we must be aware of the 
possibility of meeting with commencing 
carcinoma in a uterus immobilized by 
independent parametritic exudates. If 
in such a case we are able to make a 
diagnosis, there is the possibility of 
enucleating the uterus from the con- 
nective tissue masses in which it is 
imbedded, without opening the peri- 
toneal cavity,- the so-called extra 
peritoneal vaginal hysterectomy. This 
operation was performed years ago by 
Czerny, and it has been lately recom- 
mended by Frank. As the cases up 
to this time are so few, and the descrip- 
tions of them so incomplete, further 
experience is needed. 
Recently, vaginal hysterectomy has 
been resorted to in other diseases of 
the uterus than malignant tumors. 
Besides a not inconsiderable number of 
operations for prolapse of the uterus, 
Leopold has made the extirpation for 
severe neurosis; Bernays, Frank and 
others for retroflexion, and Frank in 
several cases of chronic granulating 
adenomatous endometritis, when com- 
plicated by haemorrhage or parametritis 
As yet the last named as indications for 4 
the operation do not seem to be gener- 
ally accepted. 
The operation itself, as far as the 
details of the procedure are concerned, 
is remakably unsettled, and it is diffi- 
cult to find two surgeons who operate 
exactly in the same manner. The 
principal object to be attained in the 
choice of operation is security against 
haemorrhage and sepsis of the abdom- 
inal cavity as well as of the vaginal 
wound. The more recent changes in 
the operation in this direction have un- 
doubtedly contributed to lessen its im- 
mediate mortality. 
The same preparatory measures are 
generally adopted as for laparotomy, 
with a view of having the alimentary 
canal empty. Thorough disinfection of 
the vagnia is, in the case of an ulcer- 
ating carcinoma, rather difficult, and 
opinions are divided whether the re- 
moval of the fetid carcinoma-tissue, 
with the sharp spoon, should take 
place a day or two before the opera- 
tion (Hegar), or whether it can be 
postponed so as to be the first step in the 
operation. (Leopold & Fritsch.) It seems 
most convenient to do all the operating 
at once, when, as has been demonstrated 
by the two last named operators, suf- 
ficient immediate disinfection can be 
had during the operation. 
The lithotomy position is the one al- 
most exclusively chosen as the most 
convenient. Only a few, such as A. 
P. Dudley, of New York, prefer to 
operate in Sims' position. Munde 
tried this position, but gave it up as 
inconvenient. It would seem that 
blood and irrigation-fluid would be 
more likely to enter the abdominal 
cavity, in Sims' position, on account of 
the difference in pressure in the vagina 
and abdominal cavity, characteristic of 
the latter position. 
It will be necessary to divide a nar- 
row vagina posteriorly, to make room 
for the operation. Simon's specula, or 
retractors of different sizes, or Fritsch's 
speculum with an apparatus for constant 
irrigation may be used. 
It does not matter whether the uterus 
is drawn down into the vulva with a 
strong loop of silk or the forceps, pro- 
vided the cervical tissue has consistency 
enough to give a good hold. Miku- 
licz's loop of silk through the lower 
part of the parametria does not help 
materially in bringing the uterus down, 
although it may assist in making the 
division of the lateral attachments 
bloodless. Fritsch lays great stress on 
commencing the operation by detach- 
ing the parametria from the sides of 
the cervix, which he accomplishes in 
the following manner: He divides the 
parametria after successive ligatures 
en masse of portions of the tissue, each 
one deeper than the preceding one, 
until after three to five such ligatures 
the lower border of the lateral ligament 
is reached. Haemorrhage from the 
uterine artery or its branches is thus 
prevented almost entirely, and the 
uterus becomes loose, and can very 
easily be brought down into the vulva 
so as to give greater facility to the suc- 
ceeding steps in the operation. 
In the detachment of the bladder and 
rectum from the cervix, Martin and 
Hegar try to avoid haemorrhage from 
the vagino-peritoneal wound surface by 
a row of sutures, including successively 
one portion after another of the tissues 
to be divided. This procedure takes 
a good deal of time, some of which may, 
however, be saved by not having to 
ligate bleeding points after the division, 
haemorrhage from which, although not 
copious, may sometimes prove very 
troublesome. 
The opening of the peritoneal cavity, 
before and behind the uterus, should al- 
ways be preceded by a renewed, thor- 
ough disinfection of the entire field of op- 
eration. Right here arises the question 
of keeping septic material out of the 
peritoneal cavity. If all haemorrhage is 
stopped by the above mentioned precau- 
tions, sepsis could only arise from con- 
tact between the peritoneum and the 
carcinomatous cervix and uterine canal. 
Fritsch recommends that the posterior 5 
fornix be left in connection with the 
uterus until the very last-that is, until 
after the detachment of the bladder and 
the ligature of the broad ligaments. A 
disinfected sponge is passed up between 
the uterus and the bladder and placed 
above and behind the fundus. To the 
sponge should be attached a loop of 
silk or silver wire (Leopold), as diffi- 
culty has sometimes been experienced 
in finding and removing a loose sponge 
from the pelvis. Fritsch draws down 
the fundus of the uterus through the 
anterior cul-de-sac while he ligates 
the broad ligaments, thus leaving the 
carcinomatous cervix in the posterior 
fornix, which has not yet been opened, 
and avoids contact with the peritoneum 
by making the division of the posterior 
fornix the last step in the detachment 
of the uterus. 
Leopold opens into Douglas' fossa 
before ligating the broad ligament, but 
he never turns-that is, ante- or retro- 
vertes the uterus. During the ligation 
of the ligaments the uterus is left in 
place, so that the carcinomatous cervix 
remains down in the vagina during the 
entire operation. 
I have some doubt whether it is con- 
venient or even possible in all cases to 
keep the uterus in situ during the liga- 
ture of the broad ligament. In my 
first case, in which the fundus was 
small, it was natural and easy. In the 
second case, in which the uterus was 
larger, I found it more easy to ante- 
vert. Thus Fritsch's advice in this 
direction appears more applicable to 
cases in general. 
Ligature of the broad ligaments is 
one of the most important steps in 
hysterectomy, inasmuch as the large 
vessels, uterine and spermatic, must be 
ligated with entire safety so as to avoid 
fatal haemorrhage. Fear of not thus 
securing the vessels from bleeding has 
brought forth a great variety of meth- 
ods to attain this end. 
The use of the galvano and thermo- 
cautery, to insure security against 
haemorrhage from the broad ligaments, 
has been occasionally tried by Ander- 
son and Simpson, and speedily aban- 
doned as unsafe; Simpson's patient died 
from secondary haemorrhage. 
Ligature en masse has been used by 
Billroth, Wolfler, Mikulicz, Schroder 
and Thiersch. The dangers of the 
ligature en masse, from its liability to slip, 
compelled Billroth to compress the liga- 
ment with strong forceps before apply- 
ing the ligature. Schroder added sev- 
eral separate ligatures. Ohlshausen 
used a Cintrat's wire constrictor, and, 
later, elastic ligature. 
Ligature in -portions.-Czerny had 
already ligatured in three portions, and 
many operators followed this method. 
Homostatic forceps left in place for 
24-36 hours. Pean. 
Partial ligature, step by step, is prob- 
ably the safest, and now the most com- 
monly adopted method. It is hardly 
necessary, as Hofmeyer proposed, to 
divide the ligament between successive 
double ligatures, as there is very little 
haemorrhage from the uterine ends of 
the vessels. Thus the single step liga- 
tures, as proposed by Sanger, and now 
used by Martin, Von Teuffel, Fritsch, 
Leopold, and many others, is at pres- 
ent regarded as the safest method of 
procedure. 
The treatment of the peritoneal and 
vaginal wound is of paramount import- 
ance, inasmuch as thereupon depends 
the prevention of septic inflammation 
in the peritoneal cavity, as well as in 
the tissues within the pelvis. Great 
diversity of opinion still prevails as to 
the best method to be adopted. 
Schatz procures drainage by keeping 
the patient in a sitting position during 
the after-treatment-a method alto- 
gether inconvenient for the patient. 
Schroder has left both wounds open; 
united the broad ligaments with the 
lateral corner of the vaginal wound, 
and placed a T shaped drainage-tube 
in Douglas' fossa. 
Ohlshausen uses a drain in Douglas' 
fossa and iodoform-gauze in the vagina. 
Martin uses a* T shaped drain in 6 
Douglas' fossa. Bottini, Simpson, 
Thiersch, Leopold, and Fritsch use 
iodoform-gauze drain from Douglas' 
fossa down into the vagina. 
The peritoneal wound has been par- 
tially united and an opening into the 
peritoneal cavity left for drainage, either 
in the center or at each corner of the 
wound (Czerny). The peritoneal wound 
has been left open and the vaginal 
wound partly united (S nger); iodo- 
form gauze in the vagina, the peritoneal 
wound united and the vaginal wound 
left open (Billroth, Wolfler, Mikulicz, 
Kaltenbach, Von Teuffel. 
The peritoneal wound has been united 
and the vaginal wound partly closed 
(Tauffer). Regarding this, Tauffer 
makes the following remarks ■ " I am 
convinced the total or partial leaving 
open of the vagino-peritoneal wound 
represents a stage in the development 
of vaginal hysterectomy which will 
soon be passed by, and that the total 
closure of the wound by suture will be 
generally adopted." 
In the most cases of vaginal hyster- 
ectomy no wound-surfaces are left in 
the peritoneal cavity, and consequently 
there seems to be nothing to drain. 
When the ligatures in the broad liga- 
ments are brought out into the vagina 
and kept there by sutures, there seems 
to be less reason to drain after vaginal 
hysterectomy than after uncomplicated 
cases of ovariotomy or oophorectomy. 
In one of my cases (Case I.) total closure 
of the wound was followed by a per- 
fectly aseptic course of after-treatment. 
Shall the ovaries and tubes be removed, 
or can they be left ? - In the ma- 
jority of vaginal hysterectomies, as yet 
on record, the ovaries and tubes have 
been left, and yet complaints of suffer- 
ings from periodical disturbances in 
these organs are of very rare occur- 
rence. Schroder and Tauffer report- 
one case each, in which pain afterward 
might be referred to the ovary. Schrod- 
er's patient had pain at the time of 
her menstrual period, but there was 
never any haemorrhage. Tauffer's 
patient had pain in an ovary, supposed 
to be included in the cicatrix. 
Fritsch advises that the ovaries and 
the tubes be removed when the pa- 
tient is young, and the organs can be 
brought down in the wound with reason- 
able ease. Leopold gives similar advice. 
Brennecke is of the opinion that the 
ovaries and tubes can always be left 
without any disadvantage to the patient. 
The ovaries, left in, seem in a short 
time to become atrophic and cease to 
have any physiological activity. He 
saw, quite commonly, especially in 
younger patients, more or less vague 
menstrual molimina in the first two to 
six months after the operation, but after 
that time they disappeared entirely. 
There would thus seem to be no reason 
to complicate hysterecto.x y, which in 
itself is a sufficiently long operation, by 
removal of the uterine appendages, 
except in cases where these are found 
to be diseased. 
The mishaps of the operation seem 
to become more and more rare, be- 
cause the advanced cases are not oper- 
ated upon, and because the require- 
ment that the uterus shall be freely 
movable is more strictly adhered to. 
Thus the difficulties in separating the 
uterus from its surroundings are the 
more easily overcome. 
Opening into the bladder still not un- 
frequently occurs, even in the hands 
of the most skillful operators (Czerny, 
Ohlshausen, Fritsch, Martin, Hofmeyr 
and others). The opening, however, 
has usually no more serious conse- 
quences than the existence of a tem- 
porary vesico-vaginal fistula, which 
generally closes spontaneously, in a few 
weeks. 
Injury to the ureter.-It was a com- 
mon occurrence in the abdominal hys- 
terectomy of Freund that one or both 
ureters were either divided or ligated. 
In the vaginal hysterectomy, injury to 
the uretur is just as rare as injury to 
the bladder is common. Starck, in 
1882, had to remove a piece of the 
ureter, because it was involved in carci- 7 
nomatous tissue. Boeckel, in 1884, had 
an injury to the ureter, probably from 
its being included in a haemostatic 
forceps, which, according to Pean's 
method of operating, was left in per- 
manently. In both cases subsequent 
nephrectomy was resorted to success- 
fully. In early operations with a mov- 
able uterus, there is in the modern 
method of operating little or no danger 
of injuring the ureter during vaginal 
hysterectomy. 
Permanent recovery, after vaginal 
hysterectomy for carcinoma, depends, as 
in all other removals of malignant tu- 
mors, partly on the anatomical charac- 
teristics of the latter, and partly upon 
early operation. The reports from the 
literature in this regard are imperfect, 
because the operation is new and the 
reports recent, and a number of patients 
have been lost sight of or their later 
condition has never been reported. 
If we consider freedom from relapse, 
two years after the operation, as a per- 
manent recovery,-a view that is gener- 
ally adopted,-it is almost astonishing to 
see a percentage of permanent recovery 
amounting to 39.2 per centum, as pub- 
lished by Munde in a select series of 
cases, which included only cases of 
early operation, eighty-two in all, with 
thirty-two permanent recoveries. Still 
more favorable are the reports published 
by Leopold, which give more than 
two-thirds, or sixty-nine per centum of 
radical cures. 
We are certainly not accustomed, 
from other fields of surgery, to expect 
so beneficial results from operations for 
malignant tumors. Is this because 
carcinomas of the uterus, in most cases, 
belong to the benignant variety, or is it 
that the uterus, being a comparatively 
well isolated organ, gives favorable 
chances for operating in healthy tissue, 
by keeping the tumor localized for a 
certain length of time ? 
Should further reports coincide with 
the foregoing statistics, it seems evident 
that vaginal hysterectomy, for carci- 
noma, gives better chances for the 
patient than operations for carcinoma 
in any other part of the body. 
Case I. Mrs. E. C. M., 28 years of 
age, married, residing in Chicago, came 
to my office on June 10, 1887. Her 
mother died of cancer of the stomach. 
The patient commenced to menstruate 
at the age of 15, and was always regu- 
lar until the time of her marriage, in 
October, 1886. After that time the 
menses became somewhat irregular, 
and shortly afterward some leucorrhoea 
appeared. The discharge gradually 
increased, and, in the spring of 1887, 
became of a somewhat fetid odor, 
which caused her to apply for treat- 
ment. In January, 1887, the menstrual 
flow was excessive, and in February 
she was examined by Dr. S. D. Jacob- 
son, of this city, who kindly informed 
me of the local condition of the patient. 
He found on the posterior side of the 
vaginal portion of the uterus a flat ero- 
sion, half an inch long and a quarter of 
an inch broad, surrounded by five or 
six small nodules looking like ovula 
Nabothi. In narcosis the erosion was 
scraped off with the sharp spoon, and 
the bleeding surface cauterized with a 
mixture of equal parts of chloride of 
zinc and alcohol. For two months it 
looked as if the loss of substance would 
heal up, but in May, a small, cauliflower- 
like excrescence appeared upon the 
surface. 
On examination, I found the follow- 
ing condition: The patient is pale, but 
not emaciated. She seems to be in 
good health, except for the discharge 
from the vagina. Examination per 
vaginam shows the right half of the 
vaginal portion of the uterus to be the 
seat of a hard nodular mass. Extir- 
pation of the carcinoma was agreed 
upon, the method of operating being 
left undecided. If vaginal amputa- 
tion of the cervix proved to be insuffi- 
cient for the removal of all the diseased 
tissue, then total extirpation of the 
uterus would have to be resorted to. 
On June 14, the patient entered Emer- 
gency Hospital. She was prepared for 8 
the operation in the usual way, by being 
kept on liquid diet for several days, by 
thorough disinfection of the vagina by 
antiseptic injections, and by shaving of 
the external genitals. 
On June 17, I operated, in the pres- 
ence of Drs. Jacobson, Hall, Senior and 
Junior, Engert, Otto and Holmboe, in 
the following manner: The patient was 
placed in lithotomy position, and the 
vagina held open by Simon's specula. 
The narrowness of the vagina necessi- 
tated bilateral incisions in its posterior 
walls. The healthy part of the vaginal 
portion was seized with heavy vulsel- 
lum forceps, and the uterus drawn 
down toward the vulva. A loop of 
heavy silk was passed through a fold 
of the lateral fornix, through the lower' 
part of the broad ligament, an inch 
outside of and above the vaginal por- 
tion, and knotted, with a view of secur- 
ing the uterine vessels, and as a help to 
the further drawing down of the uterus. 
A circular incision was now made half 
an inch outside of the carcinoma and 
the vaginal portion. The parametrium 
or lower part of the broad ligament 
was divided without much haemorrhage, 
each bleeding vessel was secured by 
forceps, and ligated with catgut. The 
uterus could now be brought down 
into the introitus. The carcinomatous 
tissue was scraped off from the ulcer- 
ated surface with a sharp spoon, leaving 
a cavity in the right posterior half of 
the cervix extending upward close to 
the internal os. 
It was therefore thought advisable 
to remove the uterus in toto. Thorough 
disinfection of the cancerous cavity and 
the vagina was now made with 1 :iooo 
corrosive sublimate solution. The dis- 
section between the uterus and bladder 
was very easily made with blunt instru- 
ments, and finally the peritoneum was 
divided in the vesico - uterine fossa. 
From this opening, a flat aseptic sponge 
was passed up in the small pelvis, and 
a loop of heavy silk was passed through 
the lower part of the body of the 
uterus, to furnish a better hold on the 
latter than the vulsellum forceps could 
give. Dissection between the cervix and 
rectum was next made with blunt in- 
struments, and the peritoneum divided. 
The remainder of the left broad liga- 
ment was secured by hooking the left 
index finger around it, and transfixed 
by a double silk ligature. It was then 
divided between this and the uterus 
without turning the body of the latter 
down into the vagina. 
All visible divided vessels were now 
ligated with catgut, the right broad 
ligament was treated as the left had 
been, without difficulty, and the uterus 
was removed. The aseptic sponge 
originally inserted was now replaced 
by a larger one, which kept the omen- 
tum and small intestines out of sight. 
The cut ends of the broad ligament 
were drawn down into the vagina, and 
united by sutures to the lateral wall of 
the cervix. As the ovaries and tubes 
did not come down easily into the 
vaginal wound, it was decided to leave 
them in. Sutures were now passed 
antero-posteriorly through the vaginal 
wall of the anterior cervix, the poste- 
rior flaps of the peritoneum, and finally 
out through the posterior vaginal wall 
into the vagina. Six such sutures were, 
for the time being, left long, and se- 
cured by haemostatic forceps. Before 
knotting these sutures, the flat sponge 
was removed from the pelvis, and the 
toilet of the pelvic abdominal cavity 
made by smaller sponges held by long 
artery forceps, until they came out dry 
and bloodless. Finally, the pelvis was 
iodoformized by means of a sponge 
dusted over with iodoform. The 
wound-surfaces between the vagina 
and peritoneum were then thoroughly 
cleansed with i: 4000 corrosive subli- 
mate solution, and iodoformized. The 
vaginal sutures were now knotted, thus 
closing hermetically at the same time 
the peritoneal cavity and the vaginal 
wound. The ends of all sutures and 
ligatures were cut off an inch and a 
half from the knot. The vagina was 
irrigated with 1:1000 corrosive subli- 9 
mate solution; dusted over with iodo- 
form; and a light pad of iodoform- 
gauze was left in the vagina. The 
posterior incisions in the introitus of the 
vagina were united with sutures and 
covered with iodoform-gauze dressing. 
The operation lasted two hours, at 
the end of which time the pulse was 90, 
and strong. There were no signs of 
collapse whatever. The course of the 
after-treatment was perfectly aseptic. 
There was no rise in temperature nor 
pulse, and no pain. For the first few 
days there was a little soreness in the 
region of the wound. After slight 
vomiting from the ether, the patient's 
appetite improved rapidly, and the first 
passage from the bowels, on the sixth 
day, was entirely painless. She sat up 
at the beginning of the third week, and 
the ligatures of the left broad ligament 
were loosened, and removed on the 
twentieth day. On the right broad 
ligament they still remained attached to 
the mortified peripheral end of the lig- 
ament, which was not detached until a 
week later. On the patient's discharge 
from the hospital, July 13, the trans- 
verse linear wound was completely 
closed. 
Case II. Mrs. M. McE., aged thirty, 
was admitted to Emergency Hospital, 
June 14, 1887, and came under my care. 
She gives the following history: Par- 
ents living, no hereditary disease in the 
family. She was married in 1878, and 
has five children. Menstruation com- 
menced at the age of fourteen, and was 
at times irregular until she reached the 
age of twenty, when it became normal. 
In the spring of 1883 she had an attack 
of pneumonia, and was then told by her 
attending physician that her uterus was 
out of place. For this she has at times 
been treated, ever since. 
Early in 1886 she was informed by 
her physician that there was an ulcera- 
tion at the neck of the uterus. A bad- 
smelling discharge commenced at about 
the same time. Until the beginning of 
1887 she had no pain. In the summer 
of 1886 she became pregnant, and was 
delivered of a female child March 23, 
1887. 
She has had a cystic goitre the size 
of a fist for many years, which has never 
caused her any serious difficulty. For 
the last four years she has been in poor 
health, suffering from repeated attacks 
of bronchitis, and has gradually become 
emaciated. 
Present Condition.-The patient is 
pale, considerably emaciated. A fluc- 
tuating tumor the size of a child's head 
takes up the anterior aspect of the neck 
from the hyoid bone to the sternum. 
It is tense and somewhat tender, as a 
result of puncture and aspiration under- 
taken in a hospital in the city, about a 
week before. The tumor is apparently 
superficially fluctuating. The tender- 
ness is most pronounced around the seat 
of the puncture. Examination of the 
thoracic organs shows nothing abnor- 
mal. She has some cough, especially on 
rising, and raises a moderate amount of 
muco-purulent matter. 
There is a discharge from the vagina 
of considerable quantity and fetid odor. 
Digital examination shows that the 
vaginal portion is transformed into an 
irregular, hard, nodulated mass, in the 
center of which the finger passes into a 
large irregular cavity, extending 
through the entire neck. The uterus 
is movable; the rectum and bladder do 
not appear to be infiltrated. There is 
no appreciable thickening in the broad 
ligaments. Pulse no, and rather weak; 
temperature is normal; there is short- 
ness of breath after exercise. 
After the usual antiseptic prepara- 
tions, I operated on June 30,1887, in the 
presence of Drs. Jacobson, Rosa 
Engert, Otto, Hall, Sr., and Jr., Guerin 
Holmboe, and Simons. The vagina haa 
to be enlarged posteriorly; the uterus 
was drawn down with vulsellum forceps, 
and the same method of procedure 
pursued as in the previous case. The 
separation of the neck of the bladder 
from the uterus was difficult, because 
the carcinoma had extended into close 
proximity to the wall of the bladder, 10 
some of the muscular tissue of which 
was removed-so much so, in fact, that 
a sound in the bladder was covered by 
mucous membrane only. The neck 
was amputated at the internal os, because 
in this instance it proved more conven- 
ient to evert the body of the uterus 
through the opening in Douglas' fossa. 
The peritoneal wound was closed by a 
row of sutures, but the vaginal wounds 
in the lacunae were left open in the 
middle for iodoform-gauze drainage. 
There was only slight haemorrhage 
during the operation, which lasted more 
than two hours. Toward the end of 
the operation the patient was very 
much collapsed, cold and almost pulse- 
less. In spite of the free use of hypo- 
dermic injections of brandy from the 
end of the operation at 2 p. m. until 
8 p. m., no reaction had taken place; 
the pulse of the wrist was 160 and 
hardly perceptible, and the patient was 
a little delirious; temperature 96° F. 
I then made a transfusion in the 
median vein of the arm of twelve ounces 
of a solution of salt, in sterilized 
water. The pulse improved somewhat 
after the transfusion. 
June 21, 8 a. m. The patient was 
uneasy all night. She slept very little 
if any; pulse very feeble and can hardly 
be counted; complains of extreme 
thirst, has not vomited. 8 p. m. Con- 
dition unchanged. June 26. The 
patient's condition has gradually im- 
proved a little. She coughs consider- 
ably, and expectorates muco-purulent 
matter. Complains of frequent and 
painful micturition. Examination of 
the urine reveals cystitis, probably 
caused by a non-disinfected catheter 
used by one of the nurses. The blad- 
der was washed out twice a day with a 
saturated solution of boracic acid. 
June 30. There is some bloody dis- 
charge from the vagina. July 15. 
Patient has been steadily improving; 
cystitis and cough less; she sits up, is 
out of bed, and eats and sleeps well. 
July 20. Patient complains of con- 
siderable pain in the goitre, with some 
difficulty in breathing-so much so that 
aspiration was deemed necessary and a 
pint of greenish fluid evacuated, con- 
taining numerous, cholesterine crystals, 
pus-cells and blood-corpuscles. Au- 
gust i. Sutures and ligatures were 
removed from the vagina, and the for- 
nix presents a healthy granulating sur- 
face, an inch and a half broad and three 
quarters of an inch in antero-posterior 
diameter. The patient left for her 
home. 
Case III. Mrs. C. H , of 
Chicago, 32 years of age, married, was 
admitted to Emergency Hospital on 
August 21, 1887, and came under my 
care. She gives the following history: 
She did not commence to menstruate 
until the age of 19; menstruation was 
always scanty, but not painful; she was 
married at the age of 21, and has one 
child, 11 years of age. Three years ago 
her husband deserted her. Nine months 
ago she went under a " specialist's " 
treatment for " ulceration of the womb." 
She did not at this time, however, suf- 
fer from any subjective symptoms 
referable to the genital organs. She 
has never had pain (slight occasional 
abdominal pains excepted) or haem- 
orrhage until shortly before her admis- 
sion to the hospital. She noticed that, 
from the middle of last winter to this 
time, she has gradually lost in weight. 
She does not appear cachectic. 
Present Condition.-Patient is some- 
what pale, but reasonably well nour- 
ished. Heart and lungs are normal. 
Urine in quantity, and, on chemical and 
microscopic examination, normal. There 
is a bloody, serous fetid discharge from 
the vagina. Vaginal examination re- 
veals an irregular, hard, nodulated 
mass, occupying the right half of the 
vaginal portion of the uterus. The 
granulated surface is about an inch in 
diameter, and shows a peripheral area 
of grayish-red, rough, granulated ap- 
pearance, surrounding a central area of 
a light, yellowish-gray color. Above 
the tumor the neck feels normal, except 
posteriorly and to the right, where it 11 
is harder than usual. The uterus is 
movable; no thickening or hardening 
of the parametria. The ovaries are 
of normal size; the body of the uterus 
somewhat enlarged; the cavity three 
inches deep. 
Diagnosis.-Carcinoma of the vagi- 
nal portion, with probable slight exten- 
sion up into the neck. It was decided 
to perform total extirpation according 
to the method of Fritsch and Leopold. 
On August 25, in the presence of 
Drs. Picard, Bernauer, Engert, Hall, 
Otto and Holmboe, I operated according 
to the method of Fritsch. The patient 
had been prepared for the operation in 
the usual way. The vagina, being very 
narrow, had to be divided posteriorly. 
Even after this had been done, the 
space was so small as to make the op- 
eration very difficult. The granulating 
surface of the carcinoma was removed 
by a sharp spoon, and the surface then 
cauterized with the ten per centum chlo- 
ride of zinc solution. The cervical 
canal, being now fully exposed, was, 
together with the uterine canal, disin- 
fected by means of cotton dipped in 
corrosive sublimate solution and iodo- 
form. A ligature was passed through 
the parametria, the uterus drawn down 
with vulsellum forceps; the left para- 
metrium incised to the extent of an 
inch, half an inch outside of the vaginal 
portion. The tissue of the left para- 
metrium was now ligated in portions, 
and then divided between the ligature 
and the uterus. Four or five such liga- 
tures were applied before the movable 
portion of the broad ligament could be 
reached by the index finger. The liga- 
tures were left long, and the bleeding 
points and visible vessels between the 
ligatures ligated separately. The right 
parametrium was now dealt with in 
exactly the same manner. This part of 
the operation was almost bloodless. 
These steps in the operation had the 
effect of making the uterus come down 
more than an inch, so as to permit the 
vaginal portion to be well outside of 
the vulva. Notwithstanding this, the 
detachment of the bladder from the 
uterus was exceedingly difficult. A 
curved steel sound in the bladder 
marked its outlines clearly, and the 
anterior fornix was incised. An at- 
tempt to separate the bladder from the 
uterus with the finger and dissecting 
forceps proved utterly futile. Every 
particle of tissue had to be divided with 
scissors. An attempt to further the 
separation by most careful use of 
closed dissecting forceps resulted in 
making an opening into the bladder a 
quarter of an inch wide. This open- 
ing was immediately united by a con- 
tinuous catgut suture, taking in only 
the muscular coat, and finally knotted 
in such a way as to draw the opening 
together like a tobacco pouch. 
Finally, after having been obliged to 
leave in situ a thin layer of uterine tis- 
sue on the wall of the bladder, the 
peritoneum was reached and the vesico- 
uterine fossa opened transversely on 
each side out to the broad ligaments. 
A good-sized flat sponge was passed 
up over and behind the body of the 
uterus, with a silk loop attached to it. 
Several vessels and bleeding points had 
to be secured on the vesical side of the 
wound. The left index finger was 
passed up behind the left broad liga- 
ment, and the latter ligated in three 
portions, and cut off from the uterus. 
The right broad ligament having been 
treated in the same manner, the uterus 
was now attached, posteriorly, only to 
the tissues between the posterior fornix 
and Douglas' fossa. This bridge of 
tissue was divided by scissors and se- 
cured by a loop. In endeavoring to 
remove the uterus there was found a 
number of long, band-like adhesions 
between the posterior surface of the 
uterus and the peritoneum in Douglas' 
fossa. Separation of these adhesions 
was followed by very troublesome, 
although not copious, haemorrhage, a 
number of bleeding points having to be 
secured and ligated separately. The 
ovaries and tubes were left, as they 
were almost immovably fixed to the 12 
sides of the pelvis, but were otherwise 
of normal appearance. On the re- 
moval of the sponge from the pelvis, a 
mass of omentum and a loop of the 
small intestine came down into the 
vagina, and were pushed back by an- 
other disinfected sponge. The ends of 
the broad ligaments were secured in 
the corners of the vaginal wound in 
the usual manner, and the peritoneal 
flaps united carefully after cleaning 
the pelvis with sponges dusted over 
with iodoform. The center of the 
vaginal wound was left open on ac- 
count of the bladder having been pene- 
trated. The vagina was thoroughly 
disinfected, and, together with the 
vaginal wound, packed loosely with 
iodoform-gauze. 
The after-treatment was entirely 
aseptic, and the patient was discharged 
from the hospital. 
Case IV. Mrs. J. M., age 39, mar- 
ried, was admitted to Emergency Hos- 
pital September 6, 1887. The patient 
resides in Wisconsin. Her family his- 
tory is good. With the exception of 
two attacks of typhoid fever in child- 
hood, she has always had good health. 
Menstruation commenced at the age of 
13, and has always been regular, but it 
was always accompanied by severe 
molimma. She was married at the age 
of nineteen, and has had four children, 
born respectively one year, three years, 
six years, and nine years after mar- 
riage. The last pregnancy terminated 
in a premature birth, the child living 
only a couple of hours. 
The patient's health was always good 
until the time of her last pregnancy, 
eleven years ago. Since then she has 
had a white discharge from the vagina, 
and has been treated for " falling of the 
womb." She has never had pain. The 
first symptom to attract attention was 
the fact that the discharges became of- 
fensive, and of a darker color. This 
was first noticed in the spring of 1887. 
In other respects all went on as usual 
until July, 1887, when the patient had 
a severe haemorrhage after her regular 
period. The haemorrhages became 
more and more frequent, occurring al- 
most every day. 
Present condition.-Patient is fat, but 
well proportioned, weighing about 180 
pounds. She is pale, but not cachectic. 
Her general health good; in fact, she 
would not have sought medical advice 
had it not been for the haemorrhages, 
which alarmed her. 
Vaginal examination reveals a nodu- 
lated, hard, ulcerating mass occupying 
the right half of the cervix. The uterus 
is movable. Right broad ligament 
rather tense, but not infiltrated. Rec- 
tum, vagina and bladder free. 
Diagnosis.-Carcinoma of the uterus. 
Treatment: Vaginal hysterectomy. 
After the usual preparatory treat- 
ment the operation was performed, Sep- 
tember 12th. The patient was anaes- 
thetized with ether and placed in lith- 
otomy position. The introitus of the 
vagina was so narrow, from over- 
abundant adipose tissue, that it was 
necessary to make a perineal incision 
on both sides. The carcinomatous 
mass was now scraped out with a sharp 
spoon, and the vagina thoroughly dis- 
infected. The uterus was seized with 
heavy vulsellum forceps, and drawn 
down as far as possible. The broad 
ligaments were so short and unyielding 
that it was impossible to draw the 
uterus as far down as in the previous 
cases, making the operation very diffi- 
cult throughout. 
Bilateral incisions were made; the 
parametria ligated in portions, as usual, 
and the uterus removed, which was 
found to be unusually large. On ac- 
count of the narrowness of the vagina, 
and the unyielding condition of the 
parts, the usual method of suturing and 
closing the wound was abandoned. 
This course was the more indicated, 
as during the operation the patient's 
pulse was very rapid, and toward the 
end she showed signs of collapse. A 
rubber drain, surrounded by iodoform- 
gauze, was introduced, and ordinary 
antiseptic dressing applied. 13 
At the end of the operation the pa- 
tient was very weak, radial pulse scarce- 
ly perceptible, necessitating the free use 
of hypodermic injections of brandy and 
ether. 
The after-treatment consisted of daily 
irrigation with boracic acid, fresh pack- 
ing of iodoform-gauze, and free use of 
stimulants. 
Four days after the operation the 
rubber drain was removed; but it was 
necessary to introduce it again two 
days later, as the discharge became 
highly offensive. It was kept in for 
two days, after which iodoform-gauze 
only was used. 
From the beginning of the third 
week after the operation, the tempera- 
ture and pulse became normal, and re- 
mained so, excepting one afternoon 
(October 6th), when she was allowed to 
sit up half an hour, after which her 
temperature went up to 1020 F. She 
was kept in bed for several days, not 
being allowed to sit up again until 
October 13th. Since that time her re- 
covery has been uninterrupted. All 
ligatures were removed, and the wound 
entirely closed. Her appetite and gen- 
eral condition are good. 
269 La Salle Avenue. 
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n. 401. Achtundvierzig Totalextirpa- 
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prolaps und schwere Neurosen. 
Billroth. - Krankheiten der Brustdriisen 
Deutsche Churgie by Billroth and Luecke. 
Lieferung 41, p. 155. 
Schmid.-Zur Statistic der Mamma Car- 
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Pawlick.- Behandlung der Uterus Carci- 
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Wallace.-British Medical Journal, Septem- 
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