FOUR CASES 
OF 
VAGINAL HYSTERECTOMY. 
BY 
J. G. PINKHAM, M.D., LYNN. 
[Reprint from Annals of Gynaecology, Boston, December, 1889.] 
Rockwell and Churchill Press, Boston. [Annals of Gynaecology, Boston, December, 1SS0.I 
I 
Part of stump. 
Os uteri. 
Stump op tumor, 
showing crater. 
SARCOMA OF BODY AND FUNDUS. 
Case I. Page [Annals of Gynaecology, Boston, December, 1889.] 
II 
A 
B 
c 
Cervix. 
Ulcerated inner 
surface. 
Thickened mall. 
CANCER OF BODY AND FUNDUS. 
See page 8. Case IV. [Reprint from Annals of Gynaecology, Boston, December, 1S89.] 
FOUR CASES 
OF 
VAGINAL HYSTERECTOMY. 
BY 
J. G. PINKHAM, M.D., LYNN. 
WITH PLATES I. AND II. 
Case I. Sarcoma of Fundus and Body. - The patient was a 
widow, 66 years of age. She had been married twice, and had had 
eleven children and two miscarriages. 
At the age of 51 she passed the menopause without disturbance of 
health. Family history excellent. Personal history that of uninterrupted 
good health until February, 1887, at which time, after a hard day's work 
at washing, a vaginal discharge, similar in appearance and amount to 
the catamenia, came on and lasted three or four days. It was not accom- 
panied with pain. Thereafter the flow recurred once in twenty-eight 
days, like regular menstruation, with no noticeable discharge from the 
vagina in the intervals, until June 16, 1888. 
At this time, during the flow, she experienced for two days pains like 
those of labor, in consequence of which a firm, dark-colored, globular 
mass, as large as a good-sized orange, was extruded from the vagina. 
After this the vaginal discharge became offensive. In August and 
September of the same year, smaller masses of similar character were 
passed. 2 
ANNALS OF GYNECOLOGY. 
On October n she was admitted to the Lynn Hospital. She was 
then somewhat pale, but had a good appetite, and was fairly strong. 
There was a continuous, bloody, and foul-smelling vaginal discharge, 
with an occasional passage of masses like those before mentioned. On 
examination the os uteri was found to be widely dilated, and protruding 
therefrom was a soft, brittle mass as large*as a man's fist. Continuous 
with this and occupying the whole uterine cavity was a tumor somewhat 
polypoid in shape, attached to the uterus high up anteriorly and to the 
right, by a broad base. Under ether the growth was removed with the 
wire 6craseur, the uterine cavity well washed out, and a mixture of pure 
carbolic acid with strong tincture of iodine, in equal parts, applied to the 
stump of the tumor. The basic portion of the growth was quite firm in 
consistence and of a grayish-white color. The central portion was softer, 
and resembled brain tissue in appearance. The outer or lower segment, 
including that part which protruded through the os, was darker in color, 
and seemed to be composed of blood-clot intermixed with sloughing por- 
tions of the growth. 
After this the vaginal discharge ceased, and the patient improved. 
On December 12 she was discharged from the hospital, feeling tolerably 
well, but having a hard lump of uncertain character deeply situated in 
the abdominal wall, just above the umbilicus. Later an abscess formed. 
This was opened and a drainage-tube inserted. The discharge of pus 
was profuse, and continued for a long time, the patient being thereby 
much reduced in strength. 
Sometime in January, 1889, the vaginal flow began again. On Jan- 
uary 31 the curette was used and a large amount of matter like that pre- 
viously described was scraped away; after which the discharge lessened, 
but did not cease entirely. On February 23 and on March 22 the curet- 
ting process was repeated, each time without ether, the patient meantime 
losing flesh and strength and becoming quite anasmic in appearance. 
The curette failed to remove the more solid basic portions of the growth. 
It was now decided that extirpation of the uterus offered the only 
rational hope of a cure or even a marked relief of the patient. She was 
accordingly readmitted to the hospital, and having been duly prepared, 
the operation was performed on the 10th of April, in the presence of Dr. 
Wm. G. Wheeler, of Chelsea, Dr. S. W. Torrey, of Beverly, and the 
hospital staff. 
In making the operation I followed very nearly the method which I 
had seen employed by Dr. E. W. Cushing, of Boston. 
The patient was placed upon her back with the hips well out over 
the end of the table, and the legs suspended by means of broad straps and FOUR CASES OF VAGINAL HYSTERECTOMY. 
3 
rings to a bar overhead. Irrigation was kept up nearly all the time 
during the operation with sublimate solution, i to 4,000, and carbolic 
solution, 1 to 100, used in alternation. 
The uterus was first curetted, it being found pretty well filled with 
the growth. Then it was plugged* with iodoform gauze, and the os 
closed with several stitches in order to prevent the discharge from coming 
in contact with the wound. As a means of making traction upon the 
uterus, a long piece of stout silk-thread was passed through both lips of 
the cervix. The posterior incision was first made, and the cul de sac of 
Douglas opened. It having been found by exploration through this 
opening that the parametria were free from disease, and the uterus not too 
large to allow of removal by the vagina, the circular incision was com- 
pleted, the uterus separated from the bladder, and the first pair of clamp 
forceps applied. As an aid in the application the finger carried up 
behind the uterus was thrust through a thin place in the broad ligament, 
and the end brought forward to be used as a guide. The included por- 
tion of the broad ligament was divided with curved scissors, the point 
being kept turned towards the uterus. A second pair of forceps having 
been applied, and the included tissues cut as before, the uterus was so 
far released from its attachments that it was easily drawn down, retro- 
verted, and the fundus brought out at the vulval opening. The upper 
part of the broad ligaments, with the tubes, was then clamped and 
severed, no attempt being made to remove the atrophied ovaries. 
The haemorrhage was slight, and there was no descent of the 
intestines. 
The vagina was loosely packed with iodoform and sublimate gauze, 
and the patient put to bed. There was no indication at any time of 
serious shock. The following notes, taken from the hospital records, 
will show the after-progress of the case : - 
"April 11. For past twenty-four hours has had considerable pain, 
except when under influence of morphine, of which she has taken in all | 
grain subcutaneously. Has slept the greater part of the time. Tempera- 
ture, 98° to 101.20 F. Pulse, 88 to 100. Very little nausea since opera- 
tion. Has taken of brandy f 3ii, and of milk gruel f §vi. Urine high 
colored. Amount in twenty-four hours, f §vi. Oozing from vagina 
slight. 
" April 12. Restless, and impatient to be moved, with some pain 
in pelvis. Clamps taken off at 3 P.M., fifty-two hours after operation, 
with decided relief to the pain. Patient slept quietly for two hours or 
more. Towards night extreme restlessness came on. Morphine as 
before, grain in twenty-four hours. Highest temperature, 102.4° ; lowest, ANNALS OF GYNECOLOGY. 
4 
ioi.8°. Pulse, looto 104. Nourishment, milk gruel, f §xiv ; brandy, f 5v. 
Urine at first high colored and cloudy; afterwards of lighter color and 
clear. Amount, f §xiv. 
" April 13. Very restless. Had but little sleep during the night. 
Morphine, grain, by the mouth subcutaneously. Highest tempera- 
ture, 102.8°; lowest, 101.5°. Pulse, 108 to 94. Nourishment, milk 
gruel, f §xxx. Urine, clear and of natural color. Amount, f gxiii. 
" April 14. Has had comfortable day, sleeping the most of the 
time. Has had no morphine, but has taken fluid extract valerian instead. 
Highest temperature, 102.6°; lowest, 99.6°. Pulse, 108 to 90. When 
temperature was highest, took 4 grains antifebrin in a teaspoonful of 
brandy. Nourishment, milk gruel, f gxxxviii; brandy, f §i. Urine, 
natural in color. Amount, f §xvi. 
"April 15. Still comfortable. Highest temperature, 100.4° ; lowest, 
99°. Pulse, 92 to 88, somewhat feeble, and intermittent at times. Brandy 
given, a teaspoonful every two hours. In a short time the pulse became 
stronger and regular. Ordered Hoff's Malt Ext., a tablespoonful every 
four hours. Has taken three pints of gruel and some coffee during the 
twenty-four hours. 
"April 16. Comfortable. Highest temperature, 99.4°; lowest, 
97.8°. Pulse, 90 to 80, of good quality. Has taken the brandy and 
malt as ordered, with milk gruel as before. A slight cough from irri- 
tation of the throat, relieved by the hospital cough-mixture.'' 
The record continues thus, showing the gradual improvement of the 
patient, with no serious symptoms at any time. On the 21st, eleven days 
after the operation, some shreddy sloughs, composed without doubt of 
the tissue which had been compressed by the clamps, came away from 
the vagina. In three weeks after the operation the patient was able to 
sit up, and shortly afterwards left for her home. She is now in good 
health. 
The clinical history of this case, and the gross appearances of the 
tumor, would seem to leave no doubt as to the nature of the disease. 
That the question might be definitely settled, a portion of the growth was 
sent to Dr. W. F. Whitney, of Harvard Medical School, for examination 
with the microscope. The following statement was received from him :-■ 
" I have examined the specimen received from you, and find that it is 
a soft, rather homogeneous growth, with relatively large lymph spaces. 
It is composed of large round and spindle cells, with little granular, 
intercellular substance. The diagnosis is spindle-cell sarcoma." 
This case may be regarded as a typical one of the class demanding 
vaginal extirpation of the uterus. The diseased tissues were so situated FOUR CASES OF VAGINAL HYSTERECTOMY. 
5 
that only in this way could complete removal be effected. There is good 
reason to hope for a permanent cure. The illustration shows the uterus 
in its full size after being kept six months in alcohol. It was cut open 
from behind down nearly to the os, and then spread open, so as to 
exhibit the interior and the broad stflmp of the tumor with its ragged 
edges and crater-like central portion. (Plate I.) 
Case II. Cancer of Cervix. - Mrs. D., aged 58, native of Ireland. 
Family history good. Married at 21, and a widow at 33. Has borne four 
children. Was first unwell at 18, and passed the menopause without dis- 
turbance of health at 45. Always well until two years ago, when she had 
an attack of rheumatism followed by a diarrhoea which lasted nine months. 
Since then she has been more or less troubled with looseness of the bowels, 
with flatulence, and griping pains. In June, 1888, a slight flow of blood 
from the vagina caused her to consult her physician. She was told that the 
matter was one of little consequence. The flow recurred in August of the 
same year, and another physician gave an opinion similar to the one stated. 
In September a recurrence of the hasmorrhage led her to seek medical 
advice again. This time the doctor expressed a fear that she might have 
cancer,, and advised her to enter the New York Hospital for Women, - 
advice which, unfortunately, she did not, or could not, follow. From 
that time until her admission to the Lynn Hospital on the 15th of June, 
1889, she had occasional attacks of flowing, always slight, with no other 
noticeable discharge from the vagina. There were some lancinating 
pains through the pelvic region, but the patient was in good flesh and 
strong, presenting no appearance of the cancerous cachexia. There had 
been no disturbance of micturition, and the urine was normal in quantity 
and quality. On examination with the finger the parts of the uterus 
accessible to the touch were found to be quite hard. The organ was in 
its natural position, and apparently not enlarged. It was movable, but 
rather less so than is usual with the healthy uterus. The tissues around 
the cervix were firm to the touch, especially in front and towards the 
left, suggesting the possibility of an invasion of the bladder wall. By 
the speculum the cervix was seen to be somewhat swollen and purplish in 
appearance. The os was slightly patulous, and within on one side could 
be seen the margin of an ulcer. From the cervical canal some scrapings 
were obtained with the curette. Under the microscope they presented 
appearances which confirmed the diagnosis previously made of malignant 
disease. 
The uterus was removed on the 18th of June, the operation being 
similar to the one before described, with some variation of detail. Only 
two sets of clamp forceps were used. 6 
ANNALS OF GYNECOLOGY. 
The bleeding was slight, and there was scarcely any shock. In 
separating the uterus from the bladder a portion of the muscular wall of 
the latter was removed. The viscus, however, was not opened at this 
time; but three days later a fistula formed, probably from the sloughing 
of the tissues, and all the urine escaped from the vagina. A soft rubber 
catheter was kept constantly in the bladder after this, and frequent 
irrigations employed. In this manner nearly all the urine was diverted 
from the fistula. Recovery was somewhat delayed by this incident; 
when the sloughs came away from the vagina, there was some haem- 
orrhage, but not enough to occasion alarm. 
On examination of the uterus after removal, the supra-vaginal portion 
of the cervix was found to be extensively softened. There were several 
distinct hard nodules outside the uterine wall in this region, to one of 
which some muscular tissue was attached. The walls of the uterus 
above showed evidences of disease nearly to the fundus. 
The woman is now (November 12) in good apparent health, and 
the fistula has closed. The nature of the disease in this case, and the 
fact that it had invaded to some extent the tissues outside the uterine 
neck before the operation, make a return extremely probable. But the 
operation performed was the only one which seemed to offer any hope 
of relief. 
Case III. Cancer of Cervix. - Mrs. L., aged 38, of American 
birth and parentage. Was married at the age of 20, and has been a 
widow for eight years. Has had two children and one miscarriage. 
In October, 1888, she was admitted to the Lynn Hospital for the first 
time, with a history of having had for some time previously more or 
less oedema of the hands and feet, with frequent micturition and con- 
siderable pain in the back and loins. On entrance she was having 
severe pain in the lumbar region, and headache every afternoon. The 
lips were somewhat cyanotic. The urine was examined, and found to 
contain casts, but no albumen. In two weeks she was discharged much 
improved. 
In July, 1889, she was again admitted to the hospital, at this time 
presenting the usual symptoms of uterine cancer. An examination 
showed the cervix to be in an advanced state of disease. There was no 
hardness of the peri-uterine tissues. The uterus was removed on the 
18th of July, the operation being more difficult than the two previously 
described, owing to the congenital meagreness of the broad ligaments, 
and the extent of the normal attachments of the uterus to the bladder 
and rectum. Owing to these causes the uterus could be drawn down 
but little, and considerable time was consumed in separating it before FOUR CASES OF VAGINAL HYSTERECTOMY. 
7 
the application of the clamps. The patient was under ether about one 
hour, but bore the operation well and experienced no nausea afterwards. 
During convalescence there was a moderate fever beginning on the 
second day and ending on the fourteenth after the operation. The 
highest temperature attained was 102.8°, on the evening of the fifth day. 
The pulse was inclined to be rapid; during the period of fever it 
ranged from 112 to 132 per minute; afterwards, for some days, from 
90 to 100. Clamps removed fifty-two hours after operation ; before the 
removal there was pain, requiring on two occasions the administra- 
tion of morphine, gr.. |, subcutaneously. For several days there was 
non-retention of urine, and later, when a moderate diarrhoea occurred, 
there was a marked lack of control over the sphincter ani. Aside 
from these incidents nothing worthy of note took place during the 
progress of the case towards recovery. The patient was enfeebled 
by the disease before the operation, and was slow in gaining her 
strength afterwards. She was able to sit up in seventeen days. On 
August 18, thirty-three days after admission, she left the hospital. 
It must be confessed that the future of this case is not very promising. 
Case IV. Cancer of Body and Fundus. - Mrs. S., aged 54, 
American. At the age of 44, having previously enjoyed good health, 
she began to have irregular, excessive, and painful menstruation. A 
physician was consulted, but the patient obtained no relief, the symp- 
toms being, as is usual under such circumstances, attributed to the change 
of life. 
In 1881 she came under the care of Dr. William G. Wheeler, by 
whose advice curetting and other thorough measures of treatment were 
resorted to. The curette was used on four different occasions, the relief 
obtained being only temporary. For the past two years the flowing and 
pain have been almost constant. Discharge offensive. Until recently 
she has declined to listen to any proposals looking towards extirpation of 
the uterus. But in September, 1889, having been strongly urged to this 
course by Dr. Wheeler, she consented to enter the Lynn Hospital, and to 
submit to the operation. On admission, she was pale, emaciated, and 
weak. Digital examination showed the vagina and cervix uteri to be in 
a state of senile atrophy, while the body and fundus were much enlarged 
and very hard. The difficulties in the way of removal seemed so great 
that I was inclined to abandon the proposed operation. Dr. Wheeler, 
however, took the ground that removal was possible, and that, as no 
other rational course of treatment was open to us, it was our duty in so 
desperate a case to give the patient her one last chance of relief. Yield- 
ing to his judgment, I operated on the 6th of September, finding my 8 
ANNALS OF GYNECOLOGY. 
anticipations of difficulty fully met. The uterus could not be drawn 
down to any extent, and nearly all the work had to be done by the touch 
without the aid of the sight. Long and patient manipulation was re- 
quired to separate the uterus from its vesical and rectal attachments, to 
apply the clamps, and sever the broad ligaments. Division of the peri- 
nsum down to the sphincter ani was necessary before extraction could be 
effected. The patient was under ether about two and a half hours. 
During the operation she was greatly prostrated, repeated subcutaneous 
injections of brandy being required to keep her alive. After the opera- 
tion she rallied slowly, remaining weak for a long time. Several sloughs 
of skin and cellular tissue formed at the sites of the hypodermic injections 
employed during the operation. 
The ulcers thus produced were slow in healing. There was consider- 
able disturbance of digestion and a moderate fever, lasting two weeks ; 
but at no time were there any alarming symptoms. Convalescence was 
protracted ; but on October 22 the patient left the hospital, being then in 
a fair condition of health. The illustration shows the ulcerated interior 
and thickened walls of the uterus full size after two months' immersion 
in alcohol. (Plate II.) 
If the disease in this case was malignant when it began ten years 
ago, its progress must be regarded as remarkably slow. Perhaps the 
treatment adopted by Dr. Wheeler may have had a tendency to keep it 
back. While it is to be hoped that the operation was not too late for a 
cure, the presence in a marked degree of the cancerous cachexia makes 
such a result less probable than it would otherwise be. 
It may be said with reference to all the cases reported, that the sur- 
gical interference should have been much earlier, in order to afford the 
best chance of cure. The result in all of them helps, however, to prove 
that vaginal hysterectomy, when performed in accordance with the im- 
proved modern method, is not an extremely dangerous operation.