Abdominal Hysterectomy 
FOR 
INTRALIGAMENTOUS FIBROID TUMOR; ENUCLEATION; 
VAGINAL FIXATION OF THE STUMP. 
Clinical Lecture delivered at St. Luke s Hospital, Chicago. 
By HENRY T. BYFORD, M.D., 
Professor of Gynaecology, Chicago Post-Gracfual<i MuiiuaPfTcIiool; Professor of Clinical 
Gynaecology, Woman’s Medical College of Chicago; Gynaecologist to St. 
Luke’s Hospital; Surgeon to the Woman’s Hospital of Chicago. 
[Reprinted from International Clinics, October, 1891.] ABDOMINAL HYSTERECTOMY FOR INTRALIGA- 
MENTOUS FIBROID TUMOR; ENUCLEA- 
TION ; VAGINAL FIXATION OF 
THE STUMP. 
CLINICAL LECTURE DELIVERED AT ST. LUKE’S HOSPITAL, CHICAGO. 
Professor of Gynaecology, Chicago Post-Graduate Medical School; Professor of 
Clinical Gynaecology, Woman's Medical College of Chicago; Gynaecologist 
to St. Luke’s Hospital; Surgeon to the Woman’s Hospital of Chicago. 
BY HENRY T. BYFORD, M.D., 
Gentlemen,—Some points about the case we have to-day are ob- 
scure, and it will be necessary to make an examination to determine 
just what the trouble is, and what we shall do. At two office exami- 
nations I diagnosticated uterine fibroid developed in the pelvic con- 
nective tissue. To-day the mass felt very much like a subperitoneal 
hsematoma. The history is indefinite. We have no history of extra- 
uterine pregnancy, nor of an acute attack to cause hsematoma, although 
there has been a suppressed menstruation. Nor has there been that 
interference with the action of the bowels which often accompanies the 
latter, particularly in the beginning. Lately her trouble has been 
increasing, and she has experienced much local distress, general weak- 
ness, and loss of appetite. There is no menorrhagia. The tumor fills 
the pelvis almost as if moulded in it, and extends above the pubes. 
The question is, Shall we make an abdominal section or shall we punc- 
ture through the vagina? If we make an abdominal section and find a 
hsematoma, we can clean it out very thoroughly and possibly stitch the 
edges of the capsule to the abdominal wall. If we make an incision 
or puncture through the vagina and find a fibroid, we may thus com- 
plicate our subsequent abdominal section. On the other hand, if we 
find a hsematoma, we can scoop out the blood-clots and drain from below 
without entering the peritoneal cavity. 
The patient is now thoroughly relaxed by the ether, and we shall 
make our final examination. She is a married woman, Nora M., forty- 4 
ABDOMINAL HYSTERECTOMY. 
four years old, and lias never been pregnant. On inspection the ab- 
domen appears somewhat full. A fibroid of this size nearly always 
causes the greatest prominence over the symphysis, at or near the median 
line. This tumor evidently does not do that. There is an indefinite 
feeling of hardness in the median line, but there is slight resonance 
over the pubes, and I can feel, while pressing, something slip like in- 
testines. These are not the usual characteristics of a fibroid. In most 
fibroids there is a definite area of dulness. Yet it is possible for a fibroid 
to be developed posteriorly and have intestinal adhesions anteriorly, and 
thus simulate a hsematoma, but such adhesions are rare. 
Now we shall have the feet elevated and make a bimanual examina- 
tion. As I push my finger into the vagina it comes upon a tumor 
about an inch behind the subpubic ligament; it is a soft solid tumor 
with an indefinite feeling of elasticity. Pressing up behind the pubes, 
I find the cervix high up in front. Bimanually I feel the uterus 
passing up on the anterior surface of this tumor. It is intimately con- 
nected and moves slightly with it. 
At a previous digital examination of the rectum the tumor seemed to 
extend below the level of the viscus. It felt as if it had developed in 
the connective tissue and become somewhat attached to the rectum, and, 
as it developed in all directions, that part of the bowel attached was 
raised up on the side of the burrowing tumor. At the same time the 
calibre of the rectum was not interfered with, as would be likely from 
so large a hfematoma. The tumor is quite definite in shape above, aud 
is reported by her physician, who is my colleague, Dr. Frank Cary, to 
be growing. 
This case illustrates the fact that at different examinations a tumor 
may feel entirely different, and that the signs and symptoms of various 
tumors or enlargements may be mixed and render a positive diagnosis 
impossible. This mass feels like a hsematoma and occupies the 
favorite position of one, but lacks the history and some of the physical 
signs. It occupies a very unusual position for a uterine fibroid and 
possesses few of the physical signs. In such cases it is always better 
to examine the patient a second time, and, if practicable, under the 
influence of ether. As the original diagnosis of fibroid made by Dr. 
Cary and myself would seem not unlikely to be correct, we shall make 
an exploratory abdominal incision and be prepared for a hysterectomy. 
In performing an operation the first thing to do is to place your 
instruments where you can reach them yourself. Being ready I take 
out a few forceps, my knife and probe-pointed scissors, and put them 
on the towel covering the pubes where they will be handy. I shall not INTERNATIONAL CLINICS. 
5 
make this incision very low down, because the bladder is, of course, 
pulled up with the uterus. I put the point of the knife on the median 
line and make a deliberate incision downward from a little below the 
umbilicus towards the pubes, cutting through the fat with one or two 
strokes. I am now down to the fascia, and we have here quite a little 
welling of blood from vessels near the bottom. By using cold water 
we can stop this bleeding, and thus escape the annoyance attending the 
use of many haemostatic forceps. I shall now make a little nick in the 
fascia to see whether I am in the median line. I find by probing that 
I am in the sheath of the right rectus muscle near the edge. Having 
located the edge of the muscle with the probe-point of the scissors, I 
rapidly slit up the fascia with them, and force the muscular edges 
apart with the knife-handle. Now I take up some of the subperi- 
toneal connective tissue with forceps, and partly cut and partly tear it 
asunder until we arrive at the denser peritoneal membrane. 
Right here I will illustrate another point in diagnosis. Not 
having cut through the peritoneum, I can palpate this tumor quite 
freely. I could stop here or go ahead. If I found a hsematoma I 
could stop. But, as it gives to the fingers the impression of a fibroid, 
I shall go ahead. In attempts at palpation through the peritoneal 
membrane, care must be taken, however, not to separate it extensively 
from its parietal connections, as subsequent suppuration would probably 
result. 
Lifting up the peritoneum with forceps and cutting through it, I 
find that the underlying omentum does not sink away from it upon 
the entrance of air, but clings to it, and is therefore adherent. This 
accounts for the sensation of something slipping which confused our 
diagnosis, and rendered the tumor more difficult of palpation than 
fibroids ordinarily are. Gently separating the delicate structure from 
the parietes, we at last get a glimpse of the corpus uteri projecting up 
out of a soft fibroid mass, like a king on a throne. I confess that 
even a king sits easier on his throne than does the surgeon stand 
before this mitred mass. Housed under overarching broad ligaments 
and filling the pelvis, there is nothing to do with it but to tear the 
mass from its stronghold, trusting that the patient’s already exhausted 
strength will endure the trial. The broad ligaments are flattened over 
it so that they cannot be ligatured beforehand, and more or less hemor- 
rhage may be expected to occur. 
Before making this desperate attack, however, we must take our 
precautions. As the patient is very fat, we clean away all fatty 
from the parietal edges, to keep it out of the abdominal cavity. We 6 
ABDOMINAL HYSTERECTOMY. 
also protect the intestines—for they are our most easily damaged struct- 
ures—from irritation, by covering them with a large flat sponge, clamped 
to the peritoneal edges by forceps. 
I want now to cut the capsule and enucleate, but this capsule does 
not separate posteriorly, and the pelvis is so evenly full of tumor that 
I cannot get at it advantageously. Even though Dr. Watkins is pull- 
ing up the fundus with vulsellum forceps, I cannot raise the mass in 
the least. I therefore rather blindly gouge down behind it with my 
fingers, tearing through the peritoneum at the posterior reflection, and 
lift the mass up. One connective-tissue strand may be easily torn, 
but when thousands of them are interwoven it requires almost stronger 
fingers than mine. It tires them out and makes them ache. I may 
truly be said to be making my living by the sweat of my brow. Gradu- 
ally, however, I get it up from its bed, and now, by the practice of as 
much delicacy of touch as I have just exhibited of vigor, I hope to be 
able to successfully ligature the upper parts of the torn broad ligaments 
at the sides of the pelvis,—still almost inaccessible with the tumor thus 
in the way. 
Having accomplished this, and cut the threads near the knots, I 
clamp the broad ligaments against the tumor by forceps as best I can. 
I now make a superficial incision through the peritoneum transversely 
across the anterior surface of the uterus, about an inch above the attach- 
ment of the bladder, and separate the peritoneum and bladder from 
the uterus down to the vagina. Now I put my rubber tubing around 
the cervix under the mass, tie it, transfix it with pedicle-pins, and am- 
putate a little above the latter. I cut a transverse wedge-shaped piece 
out of the stump so as to lessen its size, ligature it in three parts just 
above the rubber tubing, and sew up the edges with four or five in- 
terrupted coarse sutures, leaving all ends about six inches long. I cut 
the tubing off, and, as there is no bleeding, take out the pins and hold 
the blanched stump up by the long ends of the sutures. The stump 
being thus prepared, I take it in my left hand, with my thumb against 
the anterior wall reaching clear down to the vagina, and my first two 
fingers behind it in the recto-uterine cul-de-sac. By pushing down 
and separating the bladder from the vagina for about half an inch from 
the cervix, I can make my thumb and fingers meet under the external os 
uteri with only the vaginal walls intervening. (See Fig. 1.) With a 
slender pair of haemostatic forceps I punch down between my thumb 
and the cervix until the forceps-point enters the vagina, where it is felt 
by Dr. Gaven. By spreading the blades, I can draw up the anterior 
vaginal wall, and take hold of it about the puncture with other forceps. INTERNATIONAL CLINICS. 
7 
By scissor-snips I enlarge the opening laterally and anteriorly, and 
ligature a spurting arteriole with strong catgut. Now I pass the small 
forceps holding the stump sutures down through the vaginal opening 
just made, and, while Dr. Gaven 
pulls them down into the vagina, 
I assist by my thumb and fingers 
in anteverting the stump. It slides 
into place in the vagina like a foot 
in a boot, and the peritoneal cavity 
is rid of it. 
While Dr. Watkins holds back 
the intestine, I take this long cat- 
gut thread, pierce the peritoneum 
coming from the bladder at the left 
side, and attach it to the perito- 
neum posteriorly so that it draws 
the serous membrane together at 
the edge of the left broad ligament 
stump. Two or three more punc- 
tures of the needle, with care not 
to pierce too deeply, bring me with 
my continuous suture to the right broad ligament stump. Now the 
uterine pedicle is entirely shut off from the peritoneal cavity, and can 
do no harm. There is a little bloody oozing in the pelvis, owing to 
the extensive enucleation, but it is much less than there would have 
been had we not sewed up the peritoneal edges. Those of you who 
can see well, however, have noticed that I was unable, as in most 
cases, to place the catgut continuous suture so as to cover all of the 
raw surface. Hence, in closing up, I shall leave this glass drainage- 
tube, which I put in so as to reach to the bottom of the pelvis. In 
about thirty-six hours, when the bloody oozing will have become 
serous in character, I shall remove it. 
Now there is little doubt that this patient will get well. You 
may ask me why I feel so confident of her recovery, since this is 
one of the roughest and most difficult intraperitoneal operations 
imaginable. I answer, simply because there is nothing left in the 
cavity to kill her. It is not what you take out, but what you leave, 
that kills the patient, as Dr. Parkes used to say. There are no bruised 
viscera left, only a narrow catgut suture a trifle over an inch long with 
a tiny broad ligament stump at each end, and a little raw connective 
tissue, all at the bottom of the pelvis. 
Fig. 1. 
Method of Holding Stump when Punc- 
turing the Anterior Vaginal Wall with 
Slender Forceps.— V, vagina; C, cervix; L, 
ligatures. The arrow represents the direction 
of introduction of the forceps. 8 
ABDOMINAL HYSTERECTOMY. 
The external stiches being in, and the rim of the drainage-tube 
protected by a rubber dam, we have now but to draw the patient 
to the end of the table, 
put her in the lithotomy 
position, introduce our 
vaginal retractors, and 
slip this clamp (Fig. 2), 
as you see, along the 
stump sutures, over the 
auteverted stump, and 
clamp it. It reaches 
just beyond the ligatures, so as to include them. The stump will 
slough off at this point, and the slough be inclosed in its blades and 
kept from contact with the living tissues. (See Fig. 3.) After the 
separation of the slough, which will occur in two weeks, the remain- 
Fig. 2. 
Fig. 3. 
c, clamp forceps applied; p, position of stump in ventral fixation; u, normal 
position of uterus. 
ing cervix will right itself and the granulating tissue contract, so that 
in a short time the portio vaginalis will present a normal feel to the 
examining finger. 
[Later Note.—The patient made a good recovery.]