CONDITIONS OF THE GENITAL 
ORGANS WITH REFERENCE 
TO VAGINAL HYSTERECTOMY 
FOR EPITHELIOMA UTERI. 
THE 
CHARLES GREENE CITMSTON, 8.M.5., M.D., 
Boston, Mass. 
Assistant Professor of Surgical Pathology, Tufts College 
Medical School, Boston; Fellow of the American 
Association of Obstetricians and Gynecologists; 
Corresponding Member of the Association of 
(ienito-l'rthary Surgeons of France; of 
the Obstetrical and Gynecotpgical So- 
ciety of Paris; of the Pathological 
Society of Brussels, etc. 
Reprint froth November number, t7ol. Xll. 
Annals of Gynecology and Pediatry 
Boston, 1898. THE CONDITIONS OF THE GENITAL ORGANS WITH 
REFERENCE TO VAGINAL HYSTERECTOMY FOR 
EPITHELIOMA UTERI. 
CHARLES GREENE CUMSTON, 8.M.5., M.D., 
Assistant Professor of Surgical Pathology, Tufts College Medical 
School, Boston: Fellow of the American Association of Obstet- 
ricians and Gynecologists; Corresponding Member of the Associa- 
tion of Genito-Urinary Surgeons of Prance; of the Obstetrical and 
Gynecological Society of Paris; of the Pathological Society of 
Brussels, etc. 
In a recent paper read before the Section of Gynecology of the 
Suffolk District Medical Society (Remarks on the Pathology of 
Epithelioma of the Uterus with Reference to Operative Interfer- 
ence, Boston Medical and Surgical Journal, June 23, 1898), the 
writer considered the operative indications of epithelioma of the 
uterus, looked at from a pathologic standpoint, and in this short 
contribution, he desires to consider the indications furnished by 
the condition of the genital organs, and will begin with that of 
the uterus. • 
A cancerous uterus may be found either in an otherwise physio- 
logical condition, pregnant, or complicated by some pathologic 
condition, such as displacement, the presence of a neoplastic for- 
mation (other than epithelioma), or an inflammatory process. 
The relation between pregnancy and epithelioma of the cervix 
forms one of the most interesting chapters of obstetric science, but 
this belongs more to the accoucheur than to the surgeon, and we 
will only briefly indicate the conduct that should be adopted by 
the latter under these circumstances. A pregnancy, complicat- 
ing cervical cancer, gives rise to particular indications that are 
rather difficult to determine', because in this case it is not only the 
patient’s life that is to be prolonged, but we should endeavor to 
bring to the world a viable fetus, if possible. 
Two cases must be considered, viz., whether the uterus can or 
cannot be removed per vaginam, on account of its size. In the 
first instance, the condition is only present during the first half 
of gestation, and vaginal hysterectomy is possible on account of 
the considerable laxity of the vaginal tissues. Consequently, if 
the neoplasm is limited in extent, the uterus should be removed 
and the child sacrificed. 
If the neoplasm has extended so far that hysterectomy will be CHARLES GREENE CUMSTON. 
of no avail, local and general medical treatment is all that can be 
done. If it is supposed that pregnancy may go to term, if there 
is no pelvic tumor or induration of the vagina or cervix which 
would render labor difficult, the disease must be let alone, the 
patient’s strength being sustained by suitable tonics, vaginal irri- 
gations frequently and freely used, and proper dressings in cases 
of serious symptoms, such as hemorrhage, etc. On the other 
hand, if the life of the woman is in danger on account of a long 
and difficult labor, produced by a neoplastic infiltration of the 
vagina and cervix, it is proper, we think, to produce artificial 
labor. 
On the other hand, if the uterus cannot be removed per vagi- 
nam, without removing its contents, two different conditions may 
present themselves, according to whether the disease is small in 
extent and can be removed, or on the other hand, has reached 
so far that only palliative treatment is indicated. 
In the latter condition, a symptomatic treatment to bring 
pregnancy to or near term is all that can be done. If we are deal- 
ing with one of these infrequent cases where the uterus is of 
considerable size, and the neoplasm at its commencement, so that 
a radical cure may be hoped for, operative interference is called 
for. According to the conditions present, we may (1) Induce 
labor, and after a few days do a vaginal hysterectomy; (2) Ce- 
sarean operation, followed by a colpo-hysterectomy; (3) supra- 
vaginal hysterectomy, followed by immediate vaginal extirpation 
of the remaining cervix; and (4) total abdominal hysterectomy 
of the pregnant uterus. 
We will only mention inflammatory processes of the uterus 
which so often accompany carcinoma of the organ, be they con- 
secutive to, or have been present before the neoplasm, as they are 
radically cured by hysterectomy, and do not greatly increase the 
difficulty of the operation, nor make the prognosis more serious. 
The same may be said of displacements of the uterus, or prolapsus 
of the genital organs; the latter condition, of course, renders the 
operation much easier, but it also increases the danger of hemor- 
rhage. 
The bearing on carcinoma of the cervix of uterine neoplasms, 
which in most instances are fibromata, is very different, and is a 
subject for much debate. The coexistence of a fibroid and a 
carcinoma of the cervix is not an infrequent condition to find, and 
when a woman who is under treatment for a fibroid presents fetid VAGINAL HYSTERECTOMY. 
3 
discharges and severe an epitheliomatous invasion 
of the endometrium is to be suspected. 
Although, as yet, the transformation of a fibroid into epitheli- 
oma has not been distinctly demonstrated, an invasion of the 
fibroid by an epithelioma is now a well known fact, and the 
non-malignant neoplasm may be the factor in the causation of 
an epithelioma, developing in the neighboring uterine mucosa. 
It has been shown by Schroeder that in a considerable number 
of cases, the chronic inflammation of the endometrium due to the 
presence of the fibroid first sets up a proliferation of the glandu- 
lar structures. This process passes from the typical adenoma to 
an atypical form, namely, epithelioma. So, if a fibroid cannot in 
itself give rise to carcinoma, it can at least provoke it by means 
of the endometrium, and in such a case, symptomatic treatment 
should never take the place of radical operation. 
Cases of coexisting fibroma and carcinoma of the uterus are to 
be treated by hysterectomy under certain conditions, which are 
the general indications for hysterectomy for fibroid, that is to say, 
the vaginal or abdominal route must be chosen according to the 
size of the fibroid. Vaginal hysterectomy for cases of fibroid 
coexisting with epithelioma, is only rarely indicated, but if the 
non-malignant neoplasm is small, the vaginal route will give 
fewer chances of infecting the wound with carcinoma. 
We now come to the consideration of the conditions presented 
by the adnexa and the great frequency of epithelioma of the cer- 
vix during the period of genital activity of the female might lead 
one to suppose, a priori, that the coexistence of the latter with a 
pathologic condition of the tubes or ovaries is frequent. But 
such is not the case. The lesions of the ovaries that have been 
most commonly met with are secondary carcinomatous deposits 
and inflammatory lesions. 
Secondary carcinomatus deposits within the ovary probably 
take place by the lymphatic system, and when once arising in. this 
gland, they have a marked tendency to extend to the neighboring 
organs, viz.: broad ligaments, tubes, bladder, while at the surface 
of the diseased ovary, fibrous exudates and hemorrhages arise, 
which bind the intestine and peritoneum to the organ, and 
metastatic deposits extend to them. 
The presence of carcinomatous metastasis in the ovaries is an 
absolute contra-indication for either vaginal or abdominal hys- 
terectomy, because it is a certain indication that the neoplasm has 4 
CHARLES GREENE CUMSTON. 
extended far beyond the limits of the uterus, and even if a radical 
operation were undertaken, there would he great danger from in- 
testinal adhesions. Unfortunately, the diagnosis is difficult and 
requires a careful examination under narcosis, but it should al- 
ways be done, because it is about the only lesion of the ovaries 
that is a contra-indication for hysterectomy. 
Ovarian cystoma have been present in cases of cervical carci- 
noma, and in no way contra-indicate radical interference. If the 
ovary is cystic, but only slightly increased in size, the vaginal 
route is to be preferred, because ovariotomy is then a simple mat- 
ter. When the cyst is larger and unilocular, with not very thick 
walls, the cyst may be aspirated after the uterus has been re- 
moved, and then the pedicle is tied off and the cyst removed. 
But such cases will be found to be the exception, puncture being 
difficult on account of the thickness of the cyst walls, and the 
tumor must be removed through the abdomen, when a total 
hysterectomy can be done at the same time. 
Inflammatory and suppurative lesions of the ovaries, as well as 
those of the tubes, and also inflammatory infiltrations of the para- 
metrium are no contra-indication tO' vaginal hysterectomy for 
carcinoma of the cervix, but here we must bear in mind that what 
may be taken to be an inflammatory lesion of these organs, may 
be malignant instead. Inflammatory infiltrations can be differ- 
entiated from the neoplastic type in that they are more elastic and 
supple, and still more inflammatory infiltrations, even when they 
are of recent occurrence, are rarely very extensive, while in the 
case of carcinoma they are hard, diffused, and invade almost the 
entire pelvis. In order to ascertain all these physical conditions, 
a combined rectal, vaginal and abdominal palpation is necessary 
under a complete narcosis. 
A narrow or tight vagina may be an obstacle to vaginal hys- 
terectomy, in which case the abdominal route must be employed, 
but two lateral incisions carried deeply into the cellular tissue will 
often give quite enough room to work with ease. 
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