.A. 
OF 
F I I! 1! (I C S T l M () U 
Ol TIIK 
U T E E r s. 
Successfully Treated by Incisions into its Substance, the 
Os and Cervix being previously dilated by means 
of slips of the Laminaria Digitata, and 
subsequent Extraction. 
From the American Journal of the Medical Sciences, January, 1S68. i , 
AND 
.A. C Ac S E 
OF 
V A G INIS M u S : 
Treated after the Method of Sims, by Exsection of the 
Hymen and Meatus Urdnarfus, etc., etc. 
-A. 
OK 
F I I! 1! (I (' S T l M () U 
<>l T11K 
U T E \i LT S, 
Successfully Treated by Incisions into its Substance, the 
Os and Cervix being previously dilated by means 
of slips of the Laminaria Digitata, and 
subsequent Extraction. 
From the American Journal of the Medical Sciences, January, 1868. 1 , 
AND 
A C Ac S Ej 
ok 
V A G INIS M IT S : 
Treated after the Method of Sims, by Exsection of the 
Hymen and Meatus Unmarfus, etc., etc. 
OF 
NEW YORK CITY. 
From the American Journal of the Medical Sciences, October, 18O8. 
N'KW VOltK : 
ANDREW HENDERSON, PRINTER, 
109 Fulton Street. 
1868. _A_ O-A-SIE 
OK 
F I It HO l! S T U M 6 R 
OK THE 
U T E 1! US, 
Successfully Treated by Incisions into its Substance, the 
Os and Cervix being previously dilated by means 
of slips of the Laminaria Digitata, and 
subsequent Extraction. 
From the American Journal of the Medical Sciences, January, 1868. 
A XI) 
O S IEj 
OK 
V A (i INIS M U S : 
Treated after the Method of Sims, by Exsection of the 
Hymen and Meatus Urimywlis, etc., ' 
MV JOSEPH W0l(STER, M. I).,| 
or 
NEW YORK CITY. 
From the American Journal of the Medical Sciences, October, 1868 
XKYV YORK: 
ANDREW HENDERSON. PRINTER, 
109 Pulton Street. 
1868. Mus. K., native of England, aged 27 year?, of lymphatico-sangui- 
neons temperament, presented herself to me, January 10th, 18GG, to be 
treated for a uterine tumor, attended with much hemorrhage, of the 
existence of which she had become cognizant about three years before. 
Six years ago she had given birth to a child, after a perfectly natural 
labor, but had, ever since, been troubled with more or less sanguineous 
discharge. She had consulted several medical men, both in Englau 1 
and this country, but all had declined to interfere with it, owing to its 
extensive attachment to the inJde of the uterus. 
On examination, the os was found patulous ; on further dilatations 
the tumor was found to fill the uterine cavity entirely, having an 
attachment extending from the os internum for two-thirds of the entire 
length of the uterus, which svas greatly distended. The surface of the 
tumor so felt was smooth. 
In its longitudinal diameter it measured six and three-quarter 
inches, in its transverse, four and a half inches ; and did not bleed on 
touch, as polypus does. Hemorrhage was profuse and frequent, attended 
with repeated syncope, palpitation of heart, pain in back, oedema of feet 
and ankles, and anasarca throughout; indeed, a general appearance of 
anaemia. I first attempted, by means of the introduction of slips of the 
laminaria digitata, (sea-tangle,) to dilate the os uteri sufficiently to 
encircle the tumor with a ligature; but this, owing to the width of its 
base, was found to be impossible. I then determined, by repeatedly 
incising the tumor, by means of a uterotome, (Civiale’s instrument for 2 
the urethra, using it as a hysterotome,) to cut off the supply of blood 
and effect its disintegration, keeping up the dilation of the os by the 
means above mentioned, and using astringents to restrain the hemorr- 
hage. I made, on twelve different occasions, from fifteen to twenty 
incisions into the substance of the tumor, on either side of its base, 
sometimes first through the base, right and left. Much blood, was at 
first lost, but the Weeding ultimately ceased, and a considerable 
reduction in the size of the tumor took place. These operations 
occupied the time between the 221 of January and 18th of February, a 
period of twenty-seven days. Desirous of obtaining more room within 
the uterine cavity, for the continuance of my operations, I made 
persistent efforts at further dilation of the os and cervix uteri, as 
follows:— 
February 20. Introduced four slips of laminaria, which were 
allowed to remain until fully expanded: fourteen times that of the 
original size of the slip: a fact not generally known. 
22d. Introduced a long sponge tent, three-quarters of an inch in 
diameter, and three inches long, leaving it in for two and a half days. 
25th. Patient being placed under the influence of chloroform by 
my son, Dr. W. P. Worster, I,introduced into the os thirteen pieces of 
laminaria, measuring two inches in diameter; a very severe form of 
painful uterine contraction ensued, which caused me to remove them 
prematurely. The effect, however, was to cause the tumor to protrude 
at the os, from the expanding of the laminaria from above downwards. 
The fetor of the discharge was at this time intolerable, an l coagula 
escaped daily, causing much debility. The bulk of the tumor is 
rapidly diminishing. 
March 1. Introduced an India-rubber dilator, and continued the 
dilatation until the 8th, when I succeeded in introducing the fingers and 3 
part of the left hand, on which I passed up a pair of vulsellum forceps, 
and, having obtained a linn hold of the tumor, after a somewhat 
protracted and forcible traction, I extracted the entire tumor. The base 
had become softened by disintegration, from the cutting off of the 
supply of blood, which facilitated the dislodging of the mass. The 
debris, balance of the pedicle, or attached portion, followed in a few 
days. 
15th. The position of the uterus is normal. The patient is doing 
well, but very weak from loss of blood, the shock of the operation, &c. i 
under the use of brandy in very profuse quantities from the beginning of 
these operations, tonics, including quinia, iron, and the chlorate of 
potass, she regained her strength, and the natural rosy tint of her 
complexion, previously as white as marble. 
29th. She sailed for the West Indies, being in good health and 
spirits, and delighted at her riddance from her troublesome companion. 
This case may be stated as one of fibrous tumor, developed in the 
parietes of the uterus, covered by a thin layer of uterine fibre, having 
thus abroad attachment to the side of the organ; a true intra-mural 
hysteroina; not a pediculated polypus, covered only with mucuous 
membrane. The treatment consisted of two parts: one, the incisions 
into the substance of the tumor, by which its vitality and growth were 
diminished, and its substance disintegrated ; the other, the enucleation 
of the tumor itself from its investing layer of uterine muscular fibre, 
and its extraction. 
Operations for the radical cure and removal of uterine fibrous 
tumor are of recent date. In a paper on this subject, by my friend, Dr. 
IV. 0. Roberts, of this city, published in the New York Journ. of Me,d., 
in 1849, which, at the time, was, perhaps, the most complete monograph 
on the subject in our language, on p. 34 (note,) is given a case from the 4 
Rev. Med., Dec. 1841, reported by M. Filhos, in which Amussat 
enucleated, by means of the fingers alone, a fibrous tumor contained in 
the uterus. In a list of twenty-one cases, in which enucleation was 
practised, contained in the Lettsomian Lectures, &c., delivered before 
the Medical Society of London, in 18G3, by C. II. F. Iiouth, M. D., “O 1 
Fibrous Tumor of the Womb,” the first reported is by J. B. Brown, in 
1859; of these twenty-one cases, fourteen are cited as recoveries. The 
processes employed are gouging oqt pieces, breaking down tumor with 
sharp scissors, after previous incision of the os and cervix; cutting 
through capsule and gouging out apiece; removing a portion from the 
vagina, and subsequently pulling out the whole mass ; enucleation of 
half lower portion on the first day, application of whip-cord around 
separated portion, entire removal after much traction and manipulation 
three days after; incision of posterior wall, and removal of three- 
fourths of tumor by bistoury, entire removal, in two parts, by tenacu- 
lum; enucleation of three-fourths of tumor, which soon after descends 
and is extracted; incision of cervix on both sides, and extraction of 
tumor by pincers; os and cervix incised and tumor broken up, (how, not 
stated;) enucleation, in part with hand, in two operations; tumor 
crushed by lithotomy forceps, and then as much removed as possible by 
Simpson’s p’tome (sic ?). 
The operation I have reported differs from any of the above reported 
ip the incisions which were made .into the substance of the tumor, and, 
perhaps, in the mode of dilution of the os by the laminaria, the tumor 
being subsequently enucleated and removed by the vulsellnm. It adds 
another to the list of recoveries from this rather dangerous operation, in 
which the risks of hemorrhage, pyaemia, shock, and peritonitis are 
frequent and considerable. Yet the balance of success is greatly in 
favor of the operation, which, when cautiously performed, is certainly 
justifiable, and offers a fair prospect of recovery from an otherwise 5 
incurable, perhaps ultimately fatal, malady, and must be considered as a 
considerable advance in, and triumph of, obstetric surgery, and an 
important addition to our means of affording relief in a very frequent 
cause of danger and suffering in the female sex. 
Mr. Hutchinson, in Med. Times and Gaz., 1857, relates thirty-nine 
cases in which enucleation was practised. Routh has added twenty-one. 
Enucleation is primary when completed at the time, or within a day or 
two; secondary, when gangrene is induced. In the first, the incisions 
must be free and pass deeply down into the tumor, completely dividing 
the capsule and facilitating its bisection, if that should be necessary. It 
is not well to draw down the tumor too strongly, as cellulo-phlebitis, or 
peritonitis, is apt to follow. Atlee, in secondary enucleation, gave ergot 
in repeated doses, then incised the capsule, and separated the tumor from 
the cyst with the finger or. scissors, continuing this from time to time, 
until the tumor sphacelates and comes away by pieces, or what remains 
is susceptible of removal. 
Brown, as before said, uses the gouge or scissors: but latterly, as a 
safer process, incises the os, subsequently carrying the incision right 
through a portion of the tumor, (see a case in Obs. Trans.,\ol. iii., p. 76,) 
dressing the cut surfaces of the tumor with oiled lint and plugging the 
vagina. The dressings are removed in forty-eight hours, and daily 
injections of the vagina employed. The mere incision causes sloughing 
in the tumor, which disintegrates, diminishes, and finally disappears. 
Routh thinks that a series of small and successive wounds is safer than 
one large one, as producing less constitutional disturbance. Anff. 1, 1867, I was consulted in relation to Mrs. G., aged 2!) years, 
V 
married for eighteen months; coitus had, during that period, been 
impossible, owing to the excessive irritability and tenderness of the 
vulva, vagina, and surrounding parts. 
Upon examination under anaesthesia, these parts were found to be 
naturally conformed. The uterus was natural, and in situ. The hymen 
admitted of great distension with the two lingers of the right hand 
forcibly separated ; but the irritability returned as the effects of the 
chloroform passed away. 
I deferred operating for two months, owing to the heat of the 
weather; but, at the end of that time no abatement whatever had 
occurred in the severity of the symptoms. On the 1st of October I 
performed the following operation:—The patient being under the full 
influence of chloroform, assisted by W. P. Worster, M. P., and laying 
her on her left side, the limbs well drawn up and separated, I seized the 
hymen with a delicate pair of forceps, and with a small pair of very 
sharp, curved scissors, dissected out the whole of the ring, about four 
lines in thickness, including the meatus urinarius. The hemorrhage 
was slight, and less than 1 had expected. The hymen was about the 
circumference of a live-cent piece. The loss of blood having been so 
slight, I determined to proceed forthwith to finis!) the remainder of the 
operation Placing the patient on the back in the position for 
lithotomy, I passed the first and second fingers of the left hand into the 
vagina, an 1 exten le 1 them to the utterin >st: I then made an incision 7 
on either side of the posterior wall, obliquely in a line from the sac- 
roiliac symphysis to the sphincter vagina*, in the median line. This 
V-shaped double incision, of depth sufficient to divide the muscular fibre 
was continued from the point of junction forward through the raphe 
and sphincter of the vagina, to within half an inch of the anus, thus 
converting the V into a Y-shaped incision. These last cuts were made 
with Simpson’s uterotome, as better adapted for making deep incisions 
in parts partly out of sight, and less liable to wound the finger. They 
were about one-third of an inch in depth. After arresting the hemorr- 
hage, which was profuse, I packed the wounds and vagina with cotton 
saturated with glycerine, distending the orifice of the vagina to about 
one anl three-quarter inches, and then applied a T bandage. The 
packing was retained for five days. 
On the following day, when visited by my son, Dr. W. Parker 
Worster, she was found with a good pulse, and easier than had been 
expected. 
On the 5th, under chloroform, the packing was removed, and a 
glass dilator—a cylinder two and a half inches in length, and one inch 
an 1 a quarter in diameter, closed and rounded at its upper extremity, its 
edges everted at the other, and having on its upper surface a depression 
to receive the urethra—was introduced. The patient rested well. On 
the 7th I removed the dilator, and, after cleaning it and the parts, 
reintroduced it, the patient, at this latter moment, being under the 
influence of chloroform. 
Oct. 11. Repeated this proceeding without the use of chloroform; 
the patient suffering very little pain. 
loth. Removed dilator, telling patient to reinsert it every night 
anl morning; applied nitrate of silver to expelite the cicatrization of 
the intra-vaginal wounds; she sat up to-day for some hours. 8 
Sat up all day, and left in the dilator all night; 20th, went 
down stairs, and 24th, walked out by herself. 
26£/t. Improvement continues; the wounds are nearly healed, 
with only the exception of a small fissure in the lower and posterior 
floor of t'.io vagina, to which a weak solution of nitrate of silver is 
applia 1. Surgically spanking, tin cura of tha patient aul cicatrization 
of the incisions may b3 said to ba complete, and with little or no 
contraction of the vagina. 
The term “ vaginismus” seems to have been given to this affection 
which consists in an excessive hypenesthesia of the hymen and vulvar 
outlet, associated with such involuntary spasmodic contraction of the 
sphincter vaginaa as to prevent coition—by Dr. J. M. Sims, who, in 
his recent work on “Uterine Surgery,” has minutely described its 
symptoms, and recommended for its cure the operation repeated in my 
case. lie reports several cases of the affection, and several cures by 
the operation, which, he says, is “easy, safe, and certain.” On page 330 
(Uterine Surgery) he states, “ I have now operated on thirty-nine cases 
of vaginismus, and in every instance with perfect success.” To this list 
of successes, in a condition of things calculated to cause much suffering, 
both moral and physical, I.am happy to be able to add my own. 
The husband of my patient informs me (November) that the 
conjugal act is now effected without pain or repugnance ; and this day 
(Aug. 12, 1868) she is reported to me as being far advanced in preg- 
nancy, and in excellent health and spirits. 
A second case has since occurred to me treated in like manner, and, 
so far, with similar success, as to the facility of conjugal intercourse and 
the speedy recovery of the patient. 
JOSEPH WORSTER, M. D., 
54 East Ninth Street, New York.