VAGINAL HYSTERECTOMY. 
BY HENRY T. BYFORJ},* M. D., CHICAGO. 
READ BEFORE THE 
THIRTY-NINTH ANNUAL MEETING OF THE ILLINOIS 
STATE MEDICAL SOCIETY, MAY, 1889, 
AT JACKSONVILLE. 
One of the greatest and most astonishing of the many 
triumphs of modern gynecological surgery is the develop- 
ment of vaginal hysterectomy. There are comparatively 
few present who have ever seen the operation, indeed it has 
not yet been performed much more than two dozen times 
in this State. Yet the mortality is as low, other things 
being equal, as that of ovariotomy. The reason why the 
percentage of deaths seems higher is because the majority 
of the cases are malignant ones. The percentage of deaths 
in hysterectomy for non-malignant disease is very low, 
while that of ovariotomy for malignant disease is still high. 
The death rate of recent vaginal hysterectomies is about ten 
per cent, while that of some operators is even lower, and 
steadily decreasing. 
The operation is quite a simple one, although from 
smallness of vagina, adhesions, disease of the appendices, 
etc., it sometimes becomes exceedingly difficult of execu- 
tion. The steps are as follows: First, an incision through 
the vaginal wall, extending in a circular direction two-thirds 
the distance around the cervix in front and at the sides; 
second, separation of the parametric tissue from the uterus 
up to the uterine arteries at the side, and the bladder from 
the uterus in front until the peritoneum is reached; third, 
•Professor ot Diseases of Women, Chicago Post Graduate Medical School; Surgeon 
to the Woman’s Hospital; Gynecologist to St. Luke’s Hospital; Lecturer on Obstetrics, Rush 
Medical College. 2 
completion of the circular incision behind the cervix; fourth, 
opening the peritoneal cavity posteriorly and anteriorly; 
fifth, ligation or clamping of broad ligaments, and severing 
them from the uterus; sixth, tamponment of the vagina 
with iodoform gauze. 
If mal ignant disease be present in the cervix, the vaginal 
incision should be from a third to one-half an inch beyond 
the affected tissue. If arteries of any considerable size be 
cut or torn during any step of the operation previous to li- 
gation of the broad ligaments they should be transfixed by 
catgut ligatures. Small vessels may be clamped for a few 
moments with strong hemostatic forceps. After entering 
the peritoneal cavity in front of the uterus, the opening 
should be torn laterally with the fingers as far as the vesico- 
uterine folds. The incision in the recto-uterine cul-de-sac 
should be an inch or more wide, and is apt to be followed 
on either side by quite free hemorrhage. We may often 
save time, that would otherwise be spent in hunting the 
bleeding retracted vessels afterwards, by sewing the vaginal 
and peritoneal edges together completely across, so as to 
close up the retro-vaginal cellular tissue and its blood-ves- 
sels. The broad ligaments may now be ligated in sections 
from the base up, and then severed from the uterus oppo- 
site each ligature as fast as tied; or the fundus may be 
brought out through the anterior or posterior peritoneal 
opening, after ligation of the basal portions, and the twisted 
broad ligaments tied from above down. Ligation from the 
base up is, I think, preferable. Instead of using ligatures 
we may slip up a pair of hemostatic forceps, with one blade 
in front and the other behind the broad ligament, so as to 
clamp it, and, after cutting out the uterus between two 
pairs, leave them for thirty-six or forty-eight hours. As 
the uterus cannot always be pulled down sufficiently, and 
as the broad ligaments are too heavy to be included in one 
pair, it is at times advisable to place a short pair on the 
base of each ligament, cut the cervix between them, pull 3 
the uterus down, and put other forceps on the upper por- 
tion. In some recent cases I have found it preferable to 
ligature the lower or cervical portions, and place forceps 
above. One who perforins this operation should be able to 
employ any of these methods, since unexpected hindrances 
are liable to arise. I have sometimes used ligatures alone, 
sometimes forceps alone, sometimes both ligatures and for- 
ceps. I am partial to ligatures when the vagina is ample 
and the uterus can be pulled well down. But when the 
uterus is held up in the pelvis by contractions or adhesions 
about it, the forceps are to be preferred, because they can 
be slipped up along the fingers, and adjusted by the sense 
of touch. This I have been obliged to do on three occasions. 
The danger of wounding the bladder is not as great as 
was formerly supposed. In my cases I have always 
separated it with the handle of a knife or the finger, and 
have not had a mishap. 
The chief immediate danger is hemorrhage from an im- 
perfectly secured broad ligament, and the danger is, I think, 
as great, if not greater, with the use of the forceps as with 
the ligatures. By ligaturing in small portions, hemorrhage 
can be secured perfectly, while the broad ligament is apt to 
be caught by forceps in such a manner that it is very thick 
in places and thin in others. In the latter case a portion 
being only slightly compressed may slip out. On one 
occasion a pair of forceps that I was using bent a trifle, so 
that while I had it locked as tightly as possible, the ligament 
was compressed only at the base. I discovered the diffi- 
culty in time, however, to apply another pair to the upper 
loose portion, and thus avoided a possible fatal hemorrhage. 
Another possible cause of death is septic peritonitis, due 
to the leaving of a piece of a purulent Fallopian tube, or to 
a simple pelvic peritonitis arising in consequence of trauma- 
tism during the operation, or from pulling on the ligatures 
by the patient, or from her excessive restlessness. The 
peritonitis is apt to become septic from the proximity of the 4 
necrotic stump. The remedy is found in perfect quietude 
after the operation, so as to allow the inflammation about 
the incised and ligated parts to subside quickly. 
The cause of all my trouble has, however, not been in 
the operation, but in the previous condition of the patient. 
In one case of cervical carcinoma (the case which furnished 
the death) the patient was not only debilitated from bloody 
and purulent discharges, but was in such a condition from 
the use of chloral, alcohol and opium, that she was taken 
with delirium tremens on the night after the operation, got 
out of bed and endeavored to tear out her ligatures. She 
developed an abscess on the right side of the field of the 
operation; but this was small, was ready to discharge and 
would not have killed her. She died of the delirum and 
and nervous exhaustion. Another patient affected with 
intra-uterine sarcoma died in three weeks after the operation 
of heart failure. The post mortem showed the stump 
healed, and no cause for the death. She had bled profusely 
most of the time for a year before coming to me, was 
excessively anemic, and could not eat well after the opera- 
tion. She refused to take either food or nourishment four 
days before her death, and died of exhaustion. 
Quite a war of words has been waged as to whether 
amputation of the cervix and curetting would not be equally 
efficient and a preferable method in the case of cervical can- 
cer or sarcoma. Those who oppose total extirpation by 
vaginal section for carcinoma of the cervix claim that about 
as many cases suffer with relapses as after amputation of 
the cervix, and that it is a much more dangerous operation. 
There are two reasons for this tendency to relapse, viz: the 
infancy of the method, and its reservation for the worst 
cases. It may be said that the first two or three vaginal 
hysterectomies of any man are seldom well performed. 
The fear of exposing too large a surface of bleeding con- 
nective tissue, or of wounding the rectum, bladder or uret- 
ers, often prevent him from going far enough away from 
the diseased structures. I remember one case in which the 5 
operator took out the uterus successfully, but timidly kept 
so near the deceased cervix as to leave infiltrated tissue on 
the vaginal wall. Such cases spoil the statistics, and will 
do so until we get skilled and experienced operators in the 
field, and until they can get their cases early enough. The 
object of a total extirpation is to get as far away from the 
visible disease as possible. On the other hand, a large pro- 
portion of the cervical amputations are done on very early 
cases, and, therefore, cannot be compared with total extir- 
pations, which are done in more advanced cases. 
The mortality is coming down so rapidly that we can 
now call vaginal hysterectomy not much more dangerous in 
experienced hands than amputation with the cautery. 
There is actually less hemorrhage, less traumatism, and a 
smaller septic surface left. Opening the peritoneal cavity 
is not much more dangerous than the cautery (actual or 
chemical) as it is used. After removal of the uterus, hem- 
orrhage is less liable to occur than after amputation. High 
amputation after Shroeder, in which the stump is covered 
by the vagina does not admit of the removal of so much 
vaginal and cellular tissue, and may also involve great loss 
of blood. 
I would, therefore, be in favor of giving vaginal hyster- 
ectomy a trial for all cases of uterine cancer, and particu- 
larly in cases discovered early, because it is chiefly in early 
cases we can expect to get beyond the disease, and must 
make our best endeavor. Also, in view of the diminishing 
death rate, I would perform the same operation for small 
fibroids, which resist treatment and show a tendency to 
rapid growth, or produce incurable, distressing symptoms. 
Two of my cases were of this kind. Occasionally cases 
of adenoma uteri, metrorrhagia, displacement, etc., may 
require the operation, not to cure a fatal disease, but to 
relieve from a life of suffering and invalidism otherwise una- 
voidable. The death rate in cases operated upon at the 
proper times, and with the proper indications present, ought 
not to be greater than two or three per cent. Vaginal Hysterectomy. 
|No. 1 
Name and 
date of 
Operation. 
© 
C£ 
< 
Married or 
Single. 
No, of 
1 Children. 
Pathological Con- 
dition or Svmi toms 
necessitating 
Operation. 
Duration 
of 
Disease. 
Nature of Operation. 
Adhesions. 
Drainage. 
Hospital 
or 
Private. 
'Recovery 
or 
Death. 
Complications before 
or after. 
Remarks 
and 
Subsequent 
History. 
Elsewhere 
Reported. 
1 
Mrs. 8t-n. 
Aug. 3, 1887. 
29 
M 
1 
/ 
Carcinoma of cervix. 
Over a 
year. 
Multiple ligatures o 
stumps with silk ; cat 
gut ligature abou 
vaginal incision 
Left vaginal and per 
itoneal wound open 
No 
Iodoform 
gauze. 
St. Luke’s 
Hospital. 
:r 
Cervix was amputated 
several mos. before. 
No return. In good 
health. 
Chicago Medical 
Society, 1887. 
2 
Miss Ph—ps. 
5 
7 
8 
Papilioma of cervix 
Discov- 
Three haemostatic for 
No 
Iodoform 
Woman’s 
R 
Chicago Gynae- 
cological Socie- 
ty, Dec., 1887. 
Dec. 7, 1887. 
and posterior vaginal 
wall, undergoing sar- 
comatous degenera- 
tion. 
ered 1 
year 
before 
ceps to each broa< 
ligament. Catgut lig 
ature to vessels abou 
vagina] incision. 
gauze. 
Hospital. 
two months; death 
in nine or ten mos. 
1 
Mrs. G— n. 
47 
M 
2. 
Fibro-sarcoma of 
whole uterus, with 
ulceration of cavity. 
Uterus size of small 
fist. 
A denoma of fundus 
and uo-terior uterus 
wall undergoing can- 
cerous degeneration. 
8 or 10 
Multiple silk ligature 
of stump. Catgut anc 
two haemostatatic for 
ceps below. Wounu 
open, 
Retroverled uterus 
and applied multiple 
ligatures. Wound lef 
open. 
No 
Iodoform 
Woman’s 
R 
Chicago Gynae 
eological Socie- 
ty, Mar., 1888. 
Chicago Gynae- 
cological Socie- 
ty, April, 1888. 
Jan. o, ibsh. 
Mrs. Gold—t. 
March 4,1888. 
55 
M 
L,2L*t SO 
years 
ago. 
2. 
Last 17 
years. 
years. 
Un- 
known, 
but over 
a year. 
No 
gauze. 
Iodoform 
gauze. 
Hospital. 
Woman’s 
Hospital. 
R 
times, viz.: 2 
years and 1 month 
before operation. 
Thickening of right 
broad ligament, 
Cystocele before and 
after. 
Perfectly well, ex- 
cept cystocele. 
Mrs. Florence 
43 
M 
4. 
Three small intersti- 
tial fibro-myoniata. 
Incurable sienosis. 
Several years of suf- 
fering and ineffectual 
h cal treatment. 
Several 
Multiple ligatures, Cat 
gut to lower vessels 
No 
Iodoform 
It 
Cured 
Chicago Gynae- 
cological Socie- 
ty, April, 1888. 
J s 
Mar. 25, 1888. 
Last 19 
years. 
gauze. 
Hospital. 
G 
Mrs, d’B—n. 
May 17, 1888, 
5 
M 
2. 
younger 
2 years 
old. 
Cervical carcinoma in- 
volving posterior wall 
to uterus, os, and en- 
tire thickness. 
Not well 
since 
birth of 
last 
child. 
Anteverted uterus am 
applied a medium anc 
a large sized pair o 
forceps to each broac 
ligament. Catgut be 
low. Took out lef 
ovary with ligament 
cut short. 
Loop of in- 
testine tied 
off and sep- 
arated. Left 
ovary em- 
bedded in 
lymph. 
Iodoform 
gauze. 
Woman’s 
Hospital. 
R 
Left ovary enlarged 
and adherent to bot- 
tom of pelvis. Its lig 
atures sloughed out in 
three months. 
Feb., 1889, returned 
near acatrix and rec- 
tum. 
Chicago Gynae- 
cological Socie- 
ty, May, 1888. 
7 
Miss McN. 
June 9, 1888 
d.9 
s 
Subserous fibro-myo- 
A year 
Multiple ligature of 
No 
St. Luke’s 
Hospital. 
R 
Chicagn Medical 
Society, June, 
1888. 
rna of posterior wall 
of cervix, size of 
goose egg. 
or 
longer. 
broad ligament. Cat- 
gut lor lower vessels 
gauze. 
left ovary also re- 
moved, leaving liga- 
ture hanging in va- 
gina. 
In good health. 
' 
• 
• 
A 
8 
Mrs. W. K. 
52 
M 
0 
Intestinal. 
Private. 
R 
No 
Still well 
No 
July 18,1888. 
Uterine Cavity. 
years. 
ligament. Forceps to 
upper portions. Bi- 
sected Uterus to ena- 
able me to deiiver it. 
gauze. 
9 
Mrs. C. A.K. 
Aug. 4, 1888. 
39 
M 
Mill tip. 
Carcinoma of Cervix. 
Discov- 
ered a 
few 
weeks. 
Multiple ligatures. 
Sewed up cellular tis- 
sue posteriorly and 
laterially. 
No 
Iodoform 
gauze. 
St. Luke’s 
Hospital. 
Died from 
Delirium 
Tremens, 
Aug. 18, 
1888. 
Delirium Tremens. 
Abscess to right of 
stumps.; 
Abscess beside the 
right stump was 
not thought by Dr. 
Wing sufficient to 
cause death. It was 
the size of a small 
egg. 
No 
10 
48 
s 
Alveolar Sarcoma of 
rp , f f 
No 
R 
No 
This patient refused 
Chicago Gynae- 
Aug. 8, 1888. 
Interior of Uterus. 
year. 
on each ligament. 
gauze. 
Hospital. 
to eat, two we ks 
after operation, and 
died Aug. 25th, of 
heart failure. Dr. 
Wing, at post mor- 
t e m examination, 
found no cause for 
death, 
eological Socie- 
ty. 
11 
Miss Emma 
Sh—t. 
Aug. 22, 1888. 
a.« 
s 
years. 
R 
No 
Still well 
Chicago Gynae- 
Interior of Uterus. 
gauze. 
Hospital. 
eological Socie- 
ty. 
12 
Mrs. Sarah 
McK. 
Mar. 25,1889. 
53 
M 
Multip. 
Carcinoma of Cervix. 
7 or 8 
months. 
Ligatures to base of 
broad ligament. For- 
ceps to upper por- 
tions. 
Extensive 
Adhesions. 
Iodoform 
gauze. 
St. Luke’s 
Hospital. 
R 
Enlarged adherent 
tubes and ovaries. 
Uncomplicated recov- 
ery. 
Uterus could not be 
drawn down on ac- 
count of hydrosal- 
pinx and adherent 
tubes and ovaries. 
Did not disturb 
them. 
Chicago Medical 
Society, May 20, 
1889. 
13 
Mrs. Bl. 
5 
i 
M 
Multip. 
Carcinoma of Cervix. 
1 year. 
No 
Woman’s 
Hospital. 
R 
No 
May 8, 1889. 
broad ligameni. For- 
ceps to upper por- 
tions. 
gauze. 
Society, May 20, 
1889. 
14 
Mrs. M—g. 
May 20, 1889. 
35 
M 
Multip. 
Carcinoma of Cervix. 
Short 
time. 
Ligatures to base of 
broad ligament. For- 
ceps to upper por- 
tions. 
No 
Iodoform 
gauze. 
Woman’s 
Hospital. 
R 
Hemorrhage upon re- 
moval of forceps in 
36 hours. 
Hem. checked by 
tampon. 
Chicago Medical 
Society,May 2d, 
1889. 
15 
"Mrs. Ph—ps. 
52 
M 
Multip. 
Sarcoma of Cervix. 
About 1 
No 
R 
No 
No 
July 28, 1889. 
year. 
gauze. 
Hospital. 
months before. 
♦Added after presentation of report. 8 
VAGINAL HYSTERECTOMY. 
DISEASE. 
NO. 
RESULT. 
Carcinoma of body. . 
. . . I . . . 
.. .Well at end of 14 months. 
“ of cervix. 
... I . . 
... Well at the end of 21 months. 
ii “ a 
.. .Returned in 10 months. 
u u u 
. . . I . - 
... Died in 2 weeks. 
n it (i 
.. .Well at the end of 6 weeks. 
(« “ « 
. . . I . . . 
.. .Well at the end of 3 months. 
“ “ “ 
. . . I . . . 
.. .Well at the end of months. 
Sarcoma of body 
.. .Well at the end of 16 months. 
M (( « 
... Well at months. 
“ U it 
. . . I . . . 
.. .Died of exhaustion at 3 weeks. 
“ “ “ 
. . . I . . . 
. . .Well at end of 9 months. 
“ M cervix 
. . I . . 
. . Died at end of about 9 months. 
“ “ “ 
.. Convalescent. 
Fibromata 
. . I . . . 
. .Well at end of 14 mos., relieved of symptoms. 
“ 
. .Well at end of 11 mos., relieved of symptoms. 
SUMMARY.