SURGICAL TREATMENT OF 
UTERINE NEOPLASMS. 
BY 
J. C. IRISH, M. D., 
LOWELL, MASS. 
Reprint from The American Gynaecological and 
Obstetrical Journal. [Reprinted from the American Gynaecological and Obstetrical Journal 
for December, 1894 ] 
SURGICAL TREATMENT OF UTERINE NEOPLASMS, 
J. C. Irish, M. D., Lowell, Mass. 
Passing hastily in review the progress that has been made in the 
radical treatment of uterine tumors, both benign and malignant, we 
find ourselves recalling the history of abdominal surgery mainly for 
the last decade. It is true that before this time a few abdominal 
surgeons would now and then remove an immense uterine myoma in 
some desperate case in which there was no alternative. The fatality 
of these operations was necessarily great ; they were done in too 
advanced a stage of the disease, when time had surrounded the 
growth with every possible complication. They were also efforts in 
establishing an operation that will always be formidable and often 
difficult to do. 
Therefore, at that time, ten years ago, with a fatality approaching 
fifty per cent., hysterectomy received very little favor or encourage- 
ment from the profession at large. But since this prehistoric period 
of the operation, if I may so call it, abdominal hysterectomy has been 
applied to a larger range of cases of uterine fibroids and has been 
done earlier. The technique of the operation also has been con- 
stantly improved. For these reasons the marvelous result was at- 
tained of reducing the necessary fatality of supravaginal hysterec- 
tomy in six years, or up to 1890, from fifty to ten per cent. While 
the radical treatment of benign uterine neoplasms was thus rapidly 
advancing and replacing varied and useless palliative measures, 
another method of removing the uterus, directed to the cure of can- 
cer at the neck, was added. Vaginal hysterectomy in comparison 
with the supravaginal encountered at first very little opposition. In 
fact, as soon as experience and practice in removing the uterus by 
the vagina had cleared away the many difficulties that beset the early 
operations, and perfected a technique at once uniform and practica- 
ble, the operation was welcomed as one of great promise, which it has 
since partially fulfilled. Vaginal hysterectomy, that has done so J. C. Irish, M. D. 
much already, and in the future will do so much more, in saving 
women from an absolutely fatal disease, had also to a certain extent 
its period of failure and disaster. The reason for this is at once ap- 
parent. The only surgical treatment of cancer in this locality that 
had before been attempted was amputation of the cervix more or 
less high, which had been so dismal a failure that the new operation 
was eagerly welcomed by both surgeon and patient. Consequently 
most cases of cancer of the cervix that came along were operated 
upon without much regard as to the extent of the disease. Really, 
the many disasters and the very considerable fatality of these first 
hysterectomies were mainly due not so much to a technique not yet 
perfected as to the fact that in many cases the disease had involved 
surrounding structures or was complicated by tumors of the body of 
the uterus or ovaries. But as experience has gradually taught us to 
avoid operation as hopeless in cases of advanced disease, where the 
vagina and broad ligaments are involved, and to substitute another 
operation where other complications exist, the immediate death-rate 
of the operation has descended to probably less than five per cent. 
Thus, one of the two surgical resources at our command for the 
treatment of malignant neoplasms at the neck of the uterus is being 
constantly more and more restricted in its application, while, in sharp 
contrast, our operation for the treatment of benign neoplasms—name- 
ly, supravaginal hysterectomy—is being resorted to in a constantly en- 
larging class of cases. 
Following still further the history of our progress in the surgical 
treatment of these growths of the uterus, we have next to mention 
not an operation, but an appliance, and that is the Trendelenburg 
table. This came into general use only about two years ago, and its 
introduction marks an epoch of progress in abdominal surgery more 
important, possibly, than any single operation that has recently been 
devised. At first thought it would hardly seem that the position of 
the patient on whom we were operating would be a matter of very 
vital consequence ; one would think that we could almost as well 
remove these tumors in the pelvis in a horizontal position as in the 
inclined one of the Trendelenburg posture. 
But, as a matter of fact, with a fairly long abdominal incision, 
which can be extended to the pubis, because the bladder recedes from 
the anterior surface of the abdomen, and with a broad retractor sepa- 
rating widely the recti muscles, and with the intestines out of the way 
in the large abdominal cavity, the entire contents of the pelvis are 
within our view and reach. Dr. Sutton says : “Two years of experi- Surgical Treatment of Uterine Neoplasms. 
3 
ence with this posture have taught me that there is scarcely a limit to 
the possibilities of intrapelvic surgery.” And this is absolutely true 
of that form of pelvic surgery that comes within the limits of our pres- 
ent subject. The great operation of complete abdominal hysterec- 
tomy is indebted practically for its existence and entirely for its use- 
fulness to this posture. This is our only resource in dealing with 
malignant neoplasms of the uterine body, as well as certain forms of 
benign tumors which remain to be considered. 
The general impression prevails that cancer of the body of the 
uterus is an extremely rare disease. My own experience, however, 
for the past three or four years, leads me to an entirely different con- 
clusion. While not as common as cancer of the cervix or breast, still 
I believe that it occurs as frequently as does cancer of the pylorus 
or omentum. I have seen within the last year at least six examples. 
This error has arisen doubtless from the great difficulties of’diagno- 
sis that necessarily attend the inaccessible position of the neoplasm. 
Cancer of the endometrium, however, is easily diagnosticated, and is 
not a rare affection. The patient first suffers from haemorrhage. By 
dilatation and curettement we bring from the uterus granular masses 
whose malignant or benign character the microscopist can readily 
determine. Therefore, in one form of malignant disease of the uter- 
ine body, we can readily make our diagnosis and act with that 
promptitude that is always so essential in these cases. 
The diagnosis of cancer involving the general structure of the 
uterine body can be discussed more properly in connection with the 
consideration of myomata. 
Now, summarizing the surgical means at our command for the 
treatment of malignant neoplasms of the uterus, whether the neck or 
body, or both, we are confined simply to two great operations—vagi- 
nal or complete abdominal hysterectomy. You will all agree with 
me, I think, that any surgical procedure short of the two radical ones 
I have proposed is perfectly useless, and that every cancer of the 
uterus should be removed when it can be done. We have left to con- 
sider, therefore, under this branch of my subject simply the following 
questions : In what cases we should attempt the operation ; what 
results, both immediate and remote, we may hope to obtain ; and in 
what circumstances the one or the other operation is indicated. 
Whenever the disease is entirely confined to the uterus the latter 
can always be removed. Sometimes, with cancer at the os, it is im- 
possible to determine before the operation whether the infection has 
extended to the lower portion of the broad ligaments. Under these 4 
J. C. Irish, M. D. 
circumstances vaginal hysterectomy becomes difficult and dangerous, 
on account of the ureters, and occasionally impossible. When the 
anterior vagina is even slightly involved the operation again is diffi- 
cult, and invasion of the bladder is extremely probable if we remove 
the entire disease. A more extensive infection of the posterior por- 
tion of the vagina does not positively contra-indicate the operation * 
but again the proximity of the rectum is, at best, a very disturbing 
condition. But in all these cases of cancer at the mouth the fact 
that the vagina or broad ligaments have become secondarily infil- 
trated is an unerring indication of, either the long existence of the 
disease or of a very great malignancy. It shows, too, that the local 
disease has gone a long way toward a general constitutional infection. 
The after-history of cases of this kind that have been operated upon 
abundantly sustains this view. They furnished the principal exam- 
ples that were formerly so frequently quoted to the discredit of the 
operation. 
In these instances, even if vaginal hysterectomy has been per- 
formed successfully and without accident, recurrence of the disease 
is so rapid, as a rule, that we do our patient very little good. There- 
fore I would restrict vaginal hysterectomy entirely to those examples 
of cancer where the neck alone is involved, and where the operation 
can be done very early in the course of the disease. 
I am well aware that I have laid down an arbitrary rule, and that 
there are several instances in which vaginal hysterectomy has been 
done where the disease had extended much beyond the limits I have 
indicated, with the permanent cure of the patient. But, on the other 
hand, for every one of these examples there are ten where these re- 
strictions have been disregarded to the harm of the patient and the 
discredit of the operation. 
In cancer of the body of the uterus we have one single recourse— 
complete abdominal hysterectomy. What are its indications and 
limitations ? 
In malignant disease of the endometrium, the diagnosis having 
been established in the manner already suggested, the indication for 
hysterectomy is unquestionable, and is followed by permanent cure in 
a majority of cases. When there is a malignant growth confined to 
the body of the uterus, and also other tumors under the broad liga- 
ment or in the ovary, the mass of them being fairly movable, the 
operation, or at least an exploratory incision, should be made. 
Any one of the following conditions seems to me a sufficient con- 
tra-indication to any attempt at removal : Surgical Treatment of Uterine Neoplasms. 
5 
A marked decline of the general health, with great deterioration 
not due to haemorrhage; enlarged glands in the groin, or an immova- 
ble cancerous mass nearly or quite filling the pelvis. 
I fully realize that there is much of detail and precision lacking in 
these directions if we were to rely upon them entirely for the separa- 
tion of the operable from the non-operable cases. Again, the many 
and varying conditions outside of all rules that individual patients 
will present will give us many instances of doubt as to whether an 
operation is advisable or not. Under these circumstances an ex- 
ploratory incision—-a procedure of slight danger with the hope that it 
may end in a complete operation—should be made. 
We have now to consider the results we may claim for our two 
operations-—vaginal and abdominal hysterectomy. Statistics furnish 
us only an approximate means of estimating the present death-rate of 
vaginal hysterectomy, for if we were to rely upon the reports of differ- 
ent operators of their cases, the aggregate would certainly give a 
higher percentage of fatality than actually belongs to the operation, 
because these various lists contain the earlier work of the different 
men. Boldt reports forty-four cases of vaginal hysterectomy with an 
immediate mortality of six—8l/100 per cent. He reports, however, in 
1892, twelve cases with no death ; Price, of Philadelphia, reports his 
mortality as below five per cent. ; Montgomery reports twenty-four 
cases with one death ; Byford, thirty-seven cases with one death. 
My personal experience is comparatively small and recent—much too 
small to be of value statistically in estimating the death-rate of the 
operation. I have done vaginal hysterectomy eighteen times with no 
immediate fatality. 
One patient, however, died six weeks after the operation and 
probably in consequence of it. There was left a fistulous opening 
into both bladder and rectum, and death was from exhaustion. The 
loss of this case, therefore, although occurring after six weeks, was 
fairly chargeable to the operation. 
My cases of vaginal hysterectomy, aside from their small number, 
are at fault for the purposes of this discussion, because eight of them 
were done, not for cancer, but for complete prolapse. 
Of our other operation—complete abdominal hysterectomy—the 
precise results can only be approximately estimated.. You will recall 
that this operation is absolutely dependent for its existence upon the 
Trendelenburg posture, and that the latter has been in general use 
for only about two years. Therefore complete abdominal hysterec- 
tomy has been done only a comparatively few times. We are there- 6 
J. C. Irish, M. D. 
fore still unable to speak with precision as to its direct mortality, but 
from what has been done we may safely say that it is about as suc- 
cessful as supravaginal hysterectomy—that is, that the inevitable per- 
centage of mortality is not more than ten per cent. 
Hence in the treatment of malignant neoplasms of the uterus we 
have two operations of choice : one with an immediate fatality of 
five per cent.—if my estimates be accepted—and the other a fatality 
of ten per cent. ; each a means of treatment that abdominal surgery 
of the last ten years has put into our hands. And when we remember 
that so short a time ago, in the presence of uterine cancer, even in its 
commencement, we were completely helpless, we can not yet fully 
realize the great promise of these additions to our surgical resources. 
The remote results of ablation of the cancerous uterus, in one way, at 
least, are very gratifying. No unpleasant sequelae of the operation 
are left. Our patients entirely recover and suffer no serious incon- 
venience from having submitted to the operation. 
When we come to inquire into the question of the recurrence of 
the disease, we open up a sad chapter of surgical history. Taken as 
a whole, the after-history of vaginal hysterectomy would indicate 
fewer permanent cures and an earlier return of the disease than fol- 
lows excision of the cancerous breast. This bad showing is not at 
all an inherent failure of the operation, but is due to the error of 
operating on many cases past all hope of surgical aid. Again, in 
many instances, the operation is done for more advanced disease than 
is now the case in amputation of the breast. 
Really, removal of the uterus for malignant neoplasms by either 
method that has been described should give a better percentage of 
cures than operations for cancer in most other parts of the body. 
The uterus and its annexse are so much isolated from the rest of the 
organism that malignant germs are disseminated slowly, as a rule ; 
and when we come to operate we can go very wide of the disease. 
It is simply a question of early operation. The specialist, therefore, 
appeals to the physician to aid him in securing for vaginal and 
abdominal hysterectomy the fullest measure of success of which they 
are capable. 
If I may be permitted to step aside from my subject one moment, 
I will give two suggestions as to diagnosis. However trite they may 
seem, they are still very important. Whenever there is found at the 
os an ulcer, or a hard, irregular nodule, a section should immediately 
be sent to the microscopist. When a patient in middle life suffers 
from menorrhagia, or especially from metrorrhagia, investigate the Surgical Treatment of Uterine Neoplasms. 
7 
case at once. This symptom always indicates a departure of the 
uterus from a normal condition, and frequently the advent of malig- 
nancy. Unfortunately, many women are living in a “fool’s paradise,” 
in the belief that this haemorrhage is a natural attendant on the 
approaching menopause. 
The choice between vaginal and abdominal hysterectomy for re- 
moval of cancer at the mouth of the uterus will be largely a matter of 
preference with different operators. In the hands of one man the 
former operation will give the better results, while to one who has 
had much experience in abdominal work the latter operation will be 
more satisfactory. For myself, in all cases where the vagina is nar- 
row, or the uterus high up in the pelvis, and not very movable, or 
where there is any suspicion of involvement of the broad ligaments 
or other complications, I prefer the abdominal operation. I simply 
reserve vaginal hysterectomy for those cases in which the vagina is 
very roomy and where the uterus can be brought well down to the 
vulva. During the past six months I have done complete abdominal 
hysterectomy four times for cancer at the mouth, and vaginal hyster- 
ectomy three times. The abdominal operations were not so difficult 
for me as the vaginal were. The convalescence of the four patients 
in which the abdominal operation was done was more rapid and 
uncomplicated than is usually the case in removal of the uterus by 
the vagina. 
This paper has already occupied so much of the time which the 
courtesy of this Society can give to it that the discussion of the treat- 
ment of benign neoplasms must be very brief and imperfect. 
At this moment, using the words of Dr. Boldt, the treatment of 
uterine myomata is in an experimental stage ; and this utterance is 
truer to-day than it would have been three or four years ago, for our 
resources then consisted practically of a multitude of palliative and 
semi-surgical procedures and the one radical operation—supravaginal 
hysterectomy—while to-day we have discarded some of our palliative 
measures and are employing the others much less than formerly. On 
the other hand, we still have our first operation, supravaginal hyster- 
ectomy, with the pedicle fastened in the lower part of the wound, 
extraperitoneally, and several other operations that have been re- 
cently introduced ; or rather, perhaps, speaking more correctly, 
modifications of the old supravaginal operation. 
First, fixation of the pedicle below the abdominal wound, but stil 
outside of the peritonaeum (Kelley). 
Second, Byford’s method of making an incision through the vagina 8 
J. C. Irish, M. D. 
in front, beneath the bladder, and turning the pedicle down through 
that incision. 
Baer’s method, or rather the one with which Dr. Baer’s name is 
especially identified—ligating the broad ligaments and uterine arteries, 
and leaving the pedicle within the abdomen without any constriction. 
He depends, of course, upon ligature of the uterine arteries to suffi- 
ciently control all haemorrhage. 
I simply refer to these several modifications, because so far, in the 
skillful hands of their advocates, they have already given excellent 
results. They also obviate two great defects of the extraperitoneal 
treatment of the pedicle—namely, the long convalescence and the 
danger of subsequent hernia. 
Some one of them indeed may, in the future, become the operation 
that will entirely supersede the old one. For myself, I prefer com- 
plete abdominal hysterectomy rather than any of these modified 
operations I have mentioned. I have had considerable experience 
with the latter, and the results have been so satisfactory, and the 
technique has seemed to me so simple in comparison with the pro- 
cedures mentioned, that I shall continue to substitute this operation 
in place of the original one under certain conditions. Therefore at 
this time, for the radical treatment of uterine fibroids, my own surgical 
resources consist of supravaginal hysterectomy with the pedicle out- 
side, and complete abdominal hysterectomy. 
Calling your attention for a moment to the palliative methods of 
treatment for uterine myomata, probably the most valuable is curet- 
tage for the relief of haemorrhage—a single one of the many evils that 
this neoplasm inflicts upon its possessor. This procedure fails in a 
majority of cases precisely as does electrolysis, and for the same rea- 
son. Neither the sound attached to the battery nor the curette in 
the surgeon’s hands can reach the whole diseased endometrium in 
the tortuous uterine canal. In every other respect electricity, after a 
trial of seven years, has disappointed the great expectations of its 
advocates. 
Removal of tubes and ovaries as a treatment of fibroids I have 
now entirely discarded. The operation does not always arrest haem- 
orrhage or stop the growth of these tumors, nor does it prevent the 
malignant degeneration to which they are liable, while, on the 
other hand, the operation is almost as difficult and dangerous as 
hysterectomy is at the present time. 
Dr. Martin, of Chicago, has recently introduced as a palliative 
■operation ligation of the uterine arteries through the vagina. The Surgical Treatment of Uterine Neoplasms. 
9 
value of this operation is still for the future to determine. But in the 
future treatment of uterine neoplasms I believe that palliatives will 
have a small place. Palliative treatment belongs to incurable diseases. 
The addition of complete abdominal hysterectomy renders the 
means at our command for the removal of uterine myomata well-nigh 
perfect. Practically there are no longer any cases in which the opera- 
tion is impossible. The future, therefore, in this direction has for us 
no advance except in details of operation. Complete abdominal 
hysterectomy is especially indicated in those cases of small fibroids 
extending under the broad ligaments or growing from the lower seg- 
ment of the body of the uterus or neck, and packed deeply within the 
pelvis. It is precisely in this class of tumors that supravaginal 
hysterectomy has been very difficult to do, and frequently impossible. 
This operation should be selected also in other instances, in which, 
from thickness of the abdominal walls or rigidity of the pelvic floor, 
it is difficult to bring the pedicle out at the lower angle of the wound. 
On the other hand, in those instances of delayed operation—which, let 
us hope, will become rapidly less and less—where the patient’s strength 
has been seriously exhausted by haemorrhage, the size and pressure 
of the tumor or septic infection of a degenerating myoma, supravagi- 
nal hysterectomy will be the operation of choice. Under these cir- 
cumstances the length of time that the operation occupies is a very 
important factor in the result, and our old operation can be done much 
more rapidly and easily than the new. In ordinary cases we may 
choose at will the one or the other. The advantage of supravaginal 
hysterectomy is its great simplicity ; the advantages of abdominal 
hysterectomy are the shorter convalescence and diminished danger of 
subsequent hernia. 
Finally, what are the indications for hysterectomy in the treat- 
ment of uterine myomata ? Not long since, the existing or prospec- 
tive large size of the tumor was the main indication for removal that 
was recognized. The logical deduction from the teaching that these 
neoplasms were benign, and always remained so, would be, that they 
could do no harm, except from their size or their direction of growth. 
The attendant accident of haemorrhage was simply a symptom to be 
treated by palliatives. But latterly more careful and long-continued 
observations of the clinical histories of myomata in large numbers 
have corrected many errors and given us new data from which to 
formulate our rules of treatment. Only a very small proportion ever 
reach a size sufficient to make them dangerous to the life of the 
patient. J. C. Irish, M. D. 
Secondly, we are not dealing with a self-limited disease—limited 
by the menopause, as has been so generally taught. On the contrary, 
the approach of the climacteric, instead of affording relief to patients 
with myomata, is really the most dangerous period in their lives. A 
record of ninety-four cases of uterine fibroids shows that forty-three 
of them developed dangerous and formidable symptoms in patients 
between the ages of forty-two and fifty. But the greatest danger with 
which they are attended comes from their liability to various retro- 
grade changes, among which may be mentioned calcareous, necrotic, 
pus-forming, cystic, and malignant degenerations, the latter the most 
important because the most frequent and insidious of all. Out of 
one hundred and ninety-six cases, in thirty-eight, Martin, of Germany, 
found changes in the tumor which, he said, certainly represented the 
opposite of that which could be called benign. Another danger comes 
from pus-tubes and tumors of the ovary, with which they are often 
attended. When these complications occur they are fully as danger- 
ous as are pus-tubes and ovarian cysts in other patients that have no 
fibroids. 
From these few facts we may at once infer that any rule as to 
operation based on the theory that we are dealing with benign and 
consequently harmless growths can be nothing else than an incorrect 
and dangerous one. Again, small fibroids are quite as likely to be- 
come malignant as the large ones, and when they involve the body of 
the uterus we can only make a probable diagnosis as to their malig- 
nancy. In fact, it is impossible to determine with any precision 
whether these small outgrowths from the uterus were fibroid in the 
beginning or cancerous; or whether or not, beginning as fibroids, 
they have degenerated into cancer. The clinical history and general 
aspect of the patient will afford us some diagnostic aid. If she is 
pale, cachectic, debilitated, and progressively losing in strength and 
weight, malignancy of the tumor may certainly be suspected. Still, 
other forms of degeneration often produce a similar train of symp- 
toms. At any rate, the indications for removal of the tumor are 
urgent, whatever its pathological character. Remove the growth first, 
and make the diagnosis afterward. Whenever the general health of 
a patient by reason of a uterine neoplasm descends greatly from the 
normal standard, she is ever afterward an invalid until the abnormal 
growth is removed. 
It is undoubtedly true that many myomata produce no symptoms. 
There are no means of knowing how frequent such cases are, but we 
may, however, dismiss them as of little interest in the present con- Surgical Treatment of Uterine Neoplasms. 
11 
nection, for there would be no question in such instances of an opera- 
tion. But whenever a uterine myoma, large or small, begins to impair 
the general health, or produces pain enough to seriously demand re- 
lief, I would advise hysterectomy as our only means of cure. The 
operation, with its present death-rate of ten per cent., is less fatal than 
the disease, while in nine cases out of ten it brings perfect health in 
place of chronic and hopeless invalidism. 
In short, with the exception above noted, I would apply to uterine 
fibroids the general surgical rule that Mr. Bland Sutton has well indi- 
cated in the following words : “It is a noteworthy fact that most 
pathologists, who have taken comprehensive views of tumor forma- 
tion and have made it a serious and prolonged study, are of opinion 
that tumors, innocent and malignant, are in the beginning local 
troubles, and that the safest and most effectual method of dealing 
with them may be expressed in one short sentence : Thorough re- 
moval of the tumor, whenever this is possible, at the earliest possible 
moment ”