THE CLINICAL COURSE OF FORTY-SEVEN CASES OF 
CARCINOMA OF THE UTERUS SUBSEQUENT 
TO HYSTERECTOMY. 
By W. W. Russell, M. D., Associate in Gynecology. 
{Bead before the Johns Hopkins Medical Society, November 4, 1895.) 
[From The Johns Hopkins Hospital Bulletin, Nos. 56-57, November-Decembcr, 1895.] fß'rom The Johns Hopkins Hospital Bulletin, Nos. 56-57, November-December, 1895.J 
THE CLINICAL COURSE OF FORTY-SEVEN CASES OF 
CARCINOMA OF THE UTERUS SUBSEQUENT 
TO HYSTERECTOMY. 
By W. W. Russell, M. I)., Associate in Gynecology. 
(Read before the Johns Hopkins Medical Society, November 4, 1895.) 
The doubts which have existed as to the ultimate value of 
complete extirpation of the uterus for carcinomatous growths 
can with certainty be set aside. From the statistical reports of 
many operators we are now justified in claiming the possibility 
of cure in a definite number of cases, and in others relief from 
distressing symptoms for months and even years, by removal 
of the uterus. We obtain then by this operation either a cure 
or a palliative effect, very often anticipating a cure where we 
obtain only cessation for a variable period of the local dis- 
charges, hemorrhages and pain. 
It is commonly accepted that these patients usually do not 
live over two years after the appearance of the first local signs. 
If we are able then to free them from this terrible affliction 
for a longer time, even though recurrence does result in the 
end, are we not justified in the procedure? The indication 
for operation is to obtain a cure, although ultimately there 
may be only temporary relief. 
The cases which I report clearly illustrate this fact, as 
sixteen of the twenty-one cases still living have passed the 
limit of two years and are enjoying good health—a period of 
exemption amply justifying the operation. 
The following forty-seven cases of hysterectomy for carci- 
noma of the uterus include all those operated upon by Dr. 
Kelly and myself since the opening of the Gynecological 
wards in October, 1889, and in Dr. Kelly’s private practice 
up to October, 1895, giving a time limit of from one to five 
years. _______________ Many of these cases we have seen personally within the past 
three mouths, and where they lived at a distance our infor- 
mation has been obtained by writing to the local consultant 
or to the patients themselves. 
Vaginal hysterectomy was performed in forty cases, abdom- 
inal in four, and the combined operation in three cases. 
Grouping them together the results are as follows: 
Death from primary effect of operation 5 = 10 per cent. 
Patients still living 21 =44 “ 
Patients died with recurrence 16 = 34 “ 
Patients not heard from 4 = 8 “ 
Died from heart lesion. 1 = 2 “ 
Three of the deaths immediately following the operation 
were due to peritonitis and two to ligation of the ureters. 
Recurrence and death took place in the sixteen cases within 
eighteen months. The prognosis in eight of these at the 
time of operation was unfavorable. 
One patient of the twenty-one still living was operated 
upon nearly five years ago for extensive disease springing 
from the cervix. She presented herself in perfect health 
about every six months for examination, bnt we were never 
able to find any return of the trouble locally. About sixteen 
months ago there appeared in the left side of her neck above 
the clavicle a nodule, to which she called our attention. 
Since then other glands in this region, on the opposite side of 
the neck and in the axillae, have become similarly affected, 
some of which have broken down and discharged externally. 
She is at present in a critical condition. As her home is at a 
considerable distance, we are compelled to accept this as a 
metastatic manifestation. 
Two cases died within four months after the uterus was 
removed. One had at the time of operation such extensive 
infiltration on either side of the cervix that the case was con- 
sidered hopeless. The uterus in the second case was found 
during the operation to he converted into a friable carcinoma- 
tous mass adherent in every direction to the bowels, rendering 
complete enucleation impossible. 
Carcinoma of the breast developed and was removed in two 
cases several months after the uterus was extirpated. One of 3 
these died of a pre-existing heart lesion without any evidence 
of a local return, and the other is at present also free from 
any pelvic trouble, but the carcinoma has again appeared in 
the breast. 
The Fallopian tube prolapsed in three cases in which it 
had not been removed, and during the healing of the vaginal 
incision was caught so that it protruded into the vagina, 
greatly reddened and swollen. These cases upon examination 
made us suspicious that there had been a return of the disease, 
but the microscope proved their true character. Two of these 
patients are still in good health; the third died from a 
recurrence. 
Another patient returned a year after operation with a note 
from her physician stating that he had discovered a mass 
in the vaginal vault which he believed to be of a malignant 
character. There had been associated with it a profuse 
vaginal discharge, and occasionally some bleeding. This 
mass proved to be a large silk ligature which had been left 
on the broad ligament and had become imbedded in the 
granulation tissue. Since the removal of the ligature the 
patient has been absolutely well. 
The most interesting of these cases is a patient who pre- 
sented herself three months after vaginal hysterectomy for 
carcinoma of the cervix, with a fungus-like growth arising in 
the vaginal vault along the scar resulting from the operation. 
Dr. Kelly carefully dissected the mass out and thoroughly 
cauterized the surrounding area. This occurred two and a 
half years ago, and the patient at present continues to be in 
excellent health. 
Local return occurred in all the cases terminating fatally, 
but in none could we elicit any history of metastatic growths 
in other parts of the body. In the case above cited where the 
patient is still living, it seems probable that there is a meta- 
stasis to the neck and axilla. 
Pneumonia was the cause of death in one instance thirteen 
months after the operation; here there was an extensive 
malignant ulcerated area in the vaginal vault, which had 
appeared a few months after she left our care. 
Adeno-carcinoma, body of the uterus 9 cases. 
Carcinoma, cervix 38 “ 4 
Results of hysterectomy for carcinoma of the body: 
Patients still living 7 = 77 per cent. 
“ died recurrence, operation incom- 
plete 1 = 11 “ 
“ died primary effect of operation 1= 11 “ 
No. cases still living, 5 yrs. elapsed 1 
UUUQ U U 2 
UUU2 U U 2 
U U U U U 2 
The uterus was removed by supravaginal amputation in 
three cases. An ordinary vaginal hysterectomy was performed 
in the remaining six. Recurrence has taken place therefore 
only in the case where the operation was not completed. 
In some of the cases the growth had penetrated the walls of 
the uterus so that it could be seen just beneath the perito- 
neal covering, and yet no evidence of involvement of the 
lymphatics or the parametrium could be detected. The three 
cases in which the cervix was left have proved as satisfactory 
as those in which the whole uterus was removed. 
Results in hysterectomy for carcinoma of the cervix: 
Patients died from primary effect of the 
operation 4 = 10 per cent. 
Patients still living 14 =36 “ 
Patients died with recurrence 15 = 38 “ 
Patients not heard from 4 = 10 “ 
Operations over 4 years ago and patients still living 3 
(( g ii (( ii 
a 2 “ “ “ 4 
a “ u u 3 
The uterus was removed in four cases by the combined 
method. One of these died a few days after the operation 
from ligation of the ureter, and another in which the disease 
was associated with pregnancy died several months after oper- 
ation with a recurrence in the vagina. The remaiuing two 
are reported as free from any suspicious signs. 
Vaginal hysterectomy was employed in thirty-four cases, 
three of which died from the operation, and fourteen after- 
wards from the original disease. 
The four cases not accounted for up to the present time 
were considered at the time of operation favorable for cure. 
Two of them I have since seen, one two years after operation 5 
and the other one year, and both at that time showed no 
evidence of ulceration or induration by vaginal examination. 
The fourteen women who are still living do not give symp- 
toms pointing to metastasis or local recurrence, except the one 
mentioned with the nodules in the neck and axillae. This 
single case proves that even after a lapse of four years we are 
not justified in claiming a cure. We cannot at present defi- 
nitely fix a period of years beyond which a patient must 
live in order to pass the danger limit. Fritsch, Schauta, 
Hofmeier, Leopold and Boldt have followed their cases from 
five to seven years after the removal of the uterus, and even as 
late as seven years there continues to be a fall in the percent, 
of cures. Olshausen, Schauta and Fritsch report over 47 per 
cent, without recurrence after a lapse of two years. It is a 
striking fact that in our cases thus far, all recurrences but 
one have taken place within eighteen mouths.* 
We have not attempted to show the relationship of the dif- 
ferent forms of carcinoma to their tendency to recurrence, but 
the form of disease has undoubtedly a great influence upon the 
ultimate results. This point is clearly demonstrated by our 
experience, as in not a single one of the seven cases in which the 
uterus was completely removed for adeno-carcinoma of the 
body has a recurrence been noted; while in the thirty-eight 
cases where the cervix was diseased, fifteen have died with a 
return of the trouble.f 
Metastases were found only once beyond the pelvic and 
retroperitoneal glands, in ten autopsies performed in the path- 
ological laboratory upon patients in whom carcinoma of the 
uterus was present. This was an adeno-carcinoma of the 
body of the uterus, and a few nodules were found in the liver. 
In four others there were carcinomatous deposits in the pelvic 
and retroperitoneal glands. 
These observations, in conjunction with the fact that by far 
the greater majority die subsequent to hysterectomy with a 
continuation of the growth in the vagina and parametrium, 
prove the possibility of complete eradication. 
* Statistics obtained from Winter, Berliner klin. Wochenschrift, 
1891, No. 33, and Ztsch. f. Geburtsh. u. Gyn., Yol. XXIY, p. 135; 
also Boldt, American Jour. Obstet., Yol. 26, p. 517. 
f Kinkenburg (Ztsch. f. Geburtsh. u. Gyn., Yol. 23) and Hof- 
meier (same journal, Yol. 32) have made similar observations. Name. 
Seat of Disease. 
Operation. 
Date of 
Operation. 
Date of Death. 
Remote Results. 
Mrs. L. 
Cervix. Fungating mass filling 
upper portion of vagina. 
Vaginal hysterectomy. 
11-31-89 
8-30-91 
Local return. 
E. C. 
Body. 
Vaginal hysterectomy. Uterus 
ruptured during removal. 
1-2-90 
Patient continues to be in excellent 
health. 
C. G. 
Cervix. Previous operation, high 
amputation. 
Vaginal hysterectomy. First use 
of ureteral catheter. 
6-18-90 
Patient last examined 10-2-93. No sign 
of return. 
D. J. B. 
Body. 
Vaginal hysterectomy. Bladder 
opened. 
8-38-90 
Five days after op- 
eration. 
Death, peritonitis. 
Mrs. H. 
Cervix. Extensive lateral infil- 
tration. 
Vaginal hysterectomy. 
3-38-91 
Five months after 
operation. 
Local return in vaginal vault. 
M. W. 
Cervix. Fungating mass in va- 
gina. 
Vaginal hysterectomy. 
4-4-91 
Last examination 10-3-95. No evidence 
of return. 
J. B. 
Portio vag. Disease extends 1 cm. 
on vaginal walls. 
Vaginal hysterectomy. 
5-4-91 
Discharging glands in neck and axillae. 
No local return, 8-15-95. 
E. C. 
Cervix. Disease circumscribed. 
Vaginal hysterectomy. 
7-1-91 
Last seen 8-9-93. In perfect condition. 
M. A. B. 
Cervix. Fungating mass in va- 
gina. Extensive lateral involve- 
ment. 
Vaginal hysterectomy. 
11-9-91 
9-5-93 
Local return in few months. 
Dr. Miller’s 
Patient. 
Cervix. 
Vaginal hysterectomy. 
4-22-91 
Excellent health. No evidence of re- 
turn, 9-11-95. 
Mrs. W. 
Cervix. Lateral involvement. 
Myoma at fundus. 
Vaginal hysterectomy. 
13-33-91 
1-1-93 
Local return. 
K. K. 
Cervix. Extensive lateral infil- 
tration. 
Vaginal and abdominal. 
1-30-93 
Died from opera- 
tion. Ligation of 
ureters. 
Mrs. M. 
Cervix. 
Vaginal hysterectomy. Cauteri- 
zation of left pedicle on account 
of infiltrated area. Prognosis 
bad. 
3-18-93 
Patient in excellent health. No local 
return, 9-15-95. 
Miss B. 
Body. 
Incomplete vaginal hysterectomy 
on account of extensive disease 
and infiltration of fundus. 
3-33-93 
About three months 
after operation. 
Disease had broken through uterine 
wall and spread out on intestines. 
Mrs. G. 
Cervix. 
Vaginal hysterectomy. 
8-3-92 
9-38-92. Portion of tube in incision 
removed with cautery. 9-1-95, pa- 
tient in good health. 
Statistics of Forty-seyen Cases of Carcinoma. F. C. 
Cervix. Two nodules found in 
uterus entirely separate from 
cervix. 
Vaginal hysterectomy. Bladder 
perforated and afterwards closed 
with good result. Bad prog- 
nosis. 
11-27-92 
10-18-93 
12-12-95. Prolapsed tube excised. 
Local return. 
C. T. 
Cervix. Complicated by 4 months’ 
pregnancy. 
Vaginal and abdominal. 
11-10-92 
5-1-94 
Patient died in Hospital. Local return 
with perforation of bladder and rec- 
tum. 
R. A. 
Body. Associated with myoma. 
Supra-vaginal amputation. Cer- 
vical canal cauterized. 
11-28-92 
Patient in good health, 9-13-95. 
Z M. 8. 
Cervix. Fungating mass in va- 
gina. 
Vaginal hysterectomy. 
12-17-92 
5-13-93. Ulcerated area in vaginal 
vault dissected out and cauterized.— 
9-31-95. No sign of local return. 
A. E. 
Cervix. Fungating mass filling 
vagina. Invasion of vaginal 
mucosa. 
Vaginal hysterectomy. 
6-25-93 
Unable to find patient. 
Mrs. D. 
Cervix. 
Vaginal hysterectomy. 
3-6-93 
Patient continues in good health, 
10-1-95. 
Mrs. C. 
Cervix. 
Vaginal hysterectomy. 
4-12-93 
Unable to obtain information regard- 
ing patient. 
Mrs. G. 
Cervix. 
Vaginal hysterectomy. Impos- 
sible to remove all disease la- 
terally. 
4-18-93 
7-1-93 
Local return. 
E, B. 
Body. 
Vaginal hysterectomy. Uterus 
ruptured in removing. 
5-10-93 
Breast removed for cancer about one 
year after hysterectomy. 10-1-95, no 
return in vagina, but patient under 
treatment for some recurrence in 
breast. 
Mrs. 8. 
Cervix. 
Vaginal hysterectomy. 
8-30-92 
Died one year later. 
Local return. 
S. L. 
Cervix. Vagina filled with fun- 
gating mass, and infiltration for 
2 cm. about cervix. 
Vaginal hysterectomy. Bladder 
perforated. Transfusion of salt 
solution in radial artery. 
10-10-93 
8-15-94 
Local return. 
P. H. 
Cervix. Circumscribed nodule. 
Vaginal hysterectomy. 
11-8-93 
Last heard from 8-20-95. Doubtful re- 
turn in cicatrix. 
L. W. 
Body. Associated with myoma. 
Supra-vaginal amputation. 
2-15-93 
Continues in excellent health, 10-5-95. 
C. 8. 
Cervix. 
Vaginal hysterectomy. 
11-25-93 
Died from opera- 
tion. Peritonitis. 
M. F, W. 
Portio vaginalis. Disseminated 
nodules in vaginal mucosa. 
Vaginal hysterectomy. Whole 
upper third of vaginal mucosa 
removed. 
11-25-93 
2-1-95 
Death from pneumonia. Local return. 
M. G. 
Body. 
Vaginal hysterectomy. 
12-4-93 
Continues to be in excellent health, 
8-17-95. 
M. D. 
Cervix. Lateral infiltration so far 
advanced that a bad prognosis 
given. 
Vaginal hysterectomy. Bougie 
in ureter. 
12-11-93 
No evidence of local return. Patient in 
excellent health, 9-13-95. Name. 
Seat oe Disease. 
Operation. 
Date op 
Operation. 
Date of Death. 
Remote Results. 
A. R. 
Cervix. Post, lip only involved. 
Vaginal hysterectomy. 
1-31-94 
Sent by physician for examination on 
account of suspicious nodule in scar, 
which proved to be silk ligature im- 
bedded in granulation tissue. No 
evidence of return of disease, 9-13-95. 
L W. 
Cervix. Fungating mass tilling 
upper portion of vagina. Mu- 
cosa of vagina not diseased. 
Vaginal hysterectomy. Bougie 
passed into ureter. 
3-15-94 
About nine months 
after operation. 
Local return. 
N. C. J. 
Cervix. Uterus torn off above in- 
ternal os. Lateral infiltration. 
Bad prognosis. 
Vaginal hysterectomy. 
3-17-94 
6-3-94 
Local return. 
E. 0. 
Cervix. Lips entirely disappear- 
ed. Disease far advanced later- 
ally. 
Vaginal hysterectomy. Uterus 
ruptured during removal. 
3-3-94 
11-5-94 
Local return. 
8. B. H. 
Cervix. Nodules felt beneath va- 
ginal mucosa. Prognosis bad. 
Vaginal hysterectomy. Bougie iu 
ureter. Pus cavity beside uterus 
in abdomen. 
3-5-94 
Five months after 
operation. 
Local return. Death sudden. 
M. E. 
Cervix. Vagina and parametri- 
um involved. Bad prognosis. 
Vaginal hysterectomy. Nodule in 
broad lig. dissected out. 
3-5-94 
Eight months after 
operation. 
Local return. 
M. H. 
Cervix. 
Vaginal hysterectomy. 
3-7-94 
Died from opera- 
tion. 
Death due to peritonitis. 
M. Q. 
Cervix. 
Vaginal hysterectomy. 
8-31-94 
Died from opera- 
tion. 
Death due to peritonitis. 
B. Z. 
Portio vaginalis. Disease had en- 
croached upon vaginal walls 3 
cm. 
Vaginal hysterectomy. Ureter 
cut. 
8-33-94 
Ureter dissected out and sutured into 
incision in bladder. 8-15-95, no sign 
of return. No urinary difficulty. 
M. P. 
Body. 
Abdominal hysterectomy. 
7-35-94 
Perfect health when last seen, 8-18-95. 
A. R. 
Cervix. 
Combined operation, vaginal and 
abdominal. 
8-8-94 
No local induration or ulceration. 
Good health, 8-16-95. 
S. A. 
Cervix. Converted into shell. 
Combined operation, vaginal and 
abdominal. 
6-5-94 
Doctor writes that patient is in good 
condition, with no sign of recurrence 
of disease, 10-16-95. 
K. A. 
Body. 
Snpra-vaginal amputation. Cer- 
vix cupped out. 
6-30-94 
No evidence of recurrence, 9-13-95. 
8. C. 
Cervix. 
Vaginal hysterectomy. Tube 
caught in vaginal incision. 
8-17-94 
Patient in good health and without 
symptoms pointing to return, 9-17-95. 
Mrs. W. 
Cervix. 
Vaginal hysterectomy. 
11-15-91 
Died about eighteen 
months after op- 
eration. 
Carcinoma of breast removed about one 
year after the vaginal hysterectomy. 
Patient died of heart lesion.