TOTAL EXTIRPATION OF THE UTERUS 
Improved Method of Treating 
the Stump. 
BY 
CHARLES P. STRONG, M. D„ 
Physician to Out-Patients, Massachusetts General Hospital; Assist- 
ant Surgeon, Free Hospital for Women ; Assistant in 
Gynaecology, Harvard Medical School. 
Reprinted from the Boston Medical and Surgical Journal 
of December 1, 1892. 
BOSTON: 
DAMRELL & UPHAM, PUBLISHERS, 
No. 283 Washington Street. 
1892. S. J. PARKHILL & CO., PRINTERS 
BOSTON TOTAL EXTIRPATION OF THE UTERUS: 
IMPROVED METHOD OF TREATING THE 
STUMP.1 
BY CHARLES P. STRONG, M.D. 
It is not my intention to discuss the relative value 
of different operations for removal of the uterus by 
high amputation as against total extirpation, but rather 
to point out the merits which may attend the use of a 
Trendelenburg posture, and removal of the uterus in 
that position by means of abdominal incision instead 
of the more commonly used vaginal extirpation. 
The extension of the disease into the broad liga- 
ments, the presence of adhesions, the binding of the 
uterus backward, and of the ovaries and tubes together 
in one mass, render extremely difficult the possibility 
of a thorough and complete eradication of the disease, 
or a removal of the whole organ by simple vaginal 
incision. 
The operation also leaves, as commonly practised, 
a free opening from the vagina into the abdominal 
cavity, which is closed, perhaps by stuffing the vagina 
with iodoform gauze, or some such method. 
The operation which I wish to present to your no- 
tice is one which I believe occupies the position of 
combining the advantages to be gained by the ordinary 
vaginal form, that is, the complete removal of the or- 
gan ; it also enables the complete closure of the wound 
between the vagina and the abdominal cavity by its 
natural covering, that is, the peritoneum, and leaves 
less risk of infection, less chance for septic absorption 
of any kind than any other operation. 
1 Read before the Surgical Section of the Suffolk District Medical 
Society, November 2, 1892.- , 2 
It is not in any one of its particulars essentially 
new; but the combination of them all is, 1 think, re- 
cognized to be of advantage by few, if any operators. 
I think Freund's operation, which was that of total 
extirpation of the uterus through the abdominal cavity, 
was rendered so difficult by the position of the patient, 
such as would be assumed in the case of an ordinary 
laparotomy, that it has fallen practically into disuse. 
By the Trendelenburg posture, however, this is ob- 
viated. The field of view is so extended and broad- 
ened that the operative technique becomes a compar- 
atively easy matter. 
Since the first of May I have performed this opera- 
tion seven times. In only one of these cases do I 
think the removal of the organ would have been possi- 
ble by the ordinary vaginal method of operating. My 
mortality has been two out of the seven. Both of these 
were desperate cases and were unpromising from the 
start, but the election was made by the patient to have 
the operation performed rather than to suffer death 
from the cancer. I should never have undertaken the 
cases had I been obliged to rely upon the vaginal 
method alone. 
The entire success of the operation, I think, depends 
upon securing the arteries of the broad ligament be- 
fore removing the uterus, dissecting off from the ante- 
rior and posterior walls of the uterus a good layer of 
the peritoneal investment, so that the closure of the 
vaginal-abdominal wound may be made complete ; with 
this is also stripped back the bladder and rectum. 
With this done there is no danger of haemorrhage, 
there is no danger of infection ; and malignant out- 
croppings into the broad ligament and along adhesions 
between the uterus and the intestines are easily felt, 
seen and secured. 
The cases reported in detail will afford a certain 3 
similarity; so that, after describing the various steps 
of the operation, 1 shall merely give in the individual 
cases the particular point that made me elect this op- 
eration in preference to the more common one. In 
none of these, I may say, would the operation of high 
amputation have afforded any prospect of removal of 
the disease. The sutures employed have been uni- 
formly silk, the single exception is the continuous 
suture which unites the peritoneal surfaces at the com- 
pletion of the operation, which is of catgut carefully 
prepared; and I have never seen septic absorption 
from it. One death of the two came in a patient in 
whom the investing peritoneum was so thick, and also 
evidently the seat of malignant disease, that I did not 
dare to leave any behind, and so removed it entirely 
and adopted the usual method of vaginal drainage 
by iodoform gauze. Although there was no evidence 
of sepsis in this case, yet I feel the patient's chances 
would have been much better could I have closed the 
wound in my usual manner. 
I thoroughly disinfect the vagina by soap and cor- 
rosive sublimate, then scrape away all the disease 
possible, and at the same time employ the Pacquelin 
cautery and pack with iodoform gauze. This method 
secures as much asepsis as is possible in a vaginal 
operation. Opening the abdomen, the fundus of the 
uterus is seen snugly reposing against the back of the 
pelvis away from the bladder. With double hooks I 
draw the fundus as closely as possible to the abdominal 
wound, pass a ligature of silk with aneurism needles 
to include the ovarian artery and as much as possible 
of the broad ligament, pass the second suture in- 
cluding the. remainder of the broad ligament and the 
uterine artery. I similarly secure the vessels of the 
opposite side, and control any bleeding from the uterus 
by compression-forceps. Then dissect away all the 4 
peritoneal investment possible, posteriorly and ante- 
riorly ; then cut across below the junction of the cervix 
into the vagina; and rapidly remove the uterus. 
If the disease extends down the vaginal walls I 
endeavor to get below this disease before opening the 
vagina. 1 have removed down to within less than an 
inch of the vaginal orifice through the abdominal cav- 
ity- 
Believing that the tendency of the disease is greater 
to return if the tubes and ovaries are left behind, it 
has been my rule to remove these. 
The operation is accompanied by very little haem- 
orrhage, because the uterine ends of the vessels, as 
severed, are held by compression-forceps. A single 
large flat piece of gauze laid across the intestines at 
the upper end of the abdominal wound is sufficient to 
protect the general abdominal cavity from any fluid 
or from blood, which forms a pool in the retro uterine 
pouch exactly as with the patient in her ordinary posi- 
tion. The toilet of the peritoneum by this means, 
therefore, becomes very simple. A continuous suture 
of catgut closes in the peritoneum, placing peritoneal 
surface against peritoneal surface, thus securing a very 
speedy obliteration of any possibility of infection ex- 
tending from the vagina into the abdominal cavity. 
In my first operations I drained through the vagina 
with long ligatures, as suggested by Dr. Krug in his 
operation for removal of fibroids. Without going into 
details of separate cases, I will briefly indicate what 
advantage I gain by this method of operating over the 
more common one. 
In the first case, the disease invaded the right broad 
ligament to such an extent that after removal of the 
uterus, I extirpated the ligament out to its junction 
with the pelvic wall. I also removed all the vaginal 
wall, anteriorly, and posteriorly to within about one 
inch of the vulva. 5 
In the second case, there were adhesions connecting 
the uterus witli the intestines, with the bladder, and 
with the ovaries and tubes, which adhesions also were 
in part the site of malignant disease. These bands I 
was able to sever entirely from the intestinal end, thus 
preventing a possible return through disease there. 
Also, in this case, both the vagina and the broad liga- 
ments had to a certain extent become affected, and 
these were also removed. 
In the third case, along the top of the broad ligament 
there ran a single piece of small intestine, which lay 
exactly parallel with the top of the ligament, and 
which was collapsed, and could not have failed to have 
been included either in suture or in compression for- 
ceps, which might have been introduced from below 
upwards. 
The death of the patient from the ordinary vaginal 
operation would have been certain, from the compres- 
sion and sloughing of this portion of the small gut. 
The third case was one, also, of very marked adhesion, 
everything being bound together, which would have 
rendered it very difficult, though not impossible. In 
cases one and three, fibroids were complications also 
present, and to add to the dangers of an attempt at 
removal through the vagina. 
Case four was a very marked case of adhesions. 
The woman was so enormously fat that I doubt it hav- 
ing been possible to have reached from the vagina up 
to the top of the broad ligaments, certainly not to have 
differentiated them from the adherent and matted mass 
of intestine surrounding. The vagina was also impli- 
cated nearly to the vulva. This case was the one pre- 
viously mentioned, in which I was unable to secure 
enough peritoneum to close the abdominal wound. 
The patient died. 
Case five was again a case of universal adhesions 
and fibroids as well as malignant disease. < 6 
In case six, everything was adherent, and there was 
also a cyst of the broad ligament. 
In case seven there was senile atrophy of the vagina, 
with too large a uterus to be easily brought down. As 
to the result of the operation from a statistician's point 
of view, two deaths out of seven cases seem a large 
per cent. That means, however, that six of these were 
cases in which, I think, few operators would have 
dared to hope for a successful result from a vaginal 
operation, and none from high amputation. 
One of these deaths was a woman with fatty heart, 
fatty degeneration of various organs, enormous amount 
of fat in the abdomen, and with drainage vaginal-ab- 
dominal. Her operation was during that hot, pros- 
trating weather in July; and after doing very nicely 
for three days, she suddenly collapsed one night, 
and died, but not from haemorrhage. The other death 
was from shock following the operation. The oper- 
ation was tedious; and the dissection out of the intes- 
tines was extremely difficult in every way. There was 
also the complication of a cyst in the broad ligament 
to add to the danger. The woman died, according to 
the result of the autopsy, of general peritonitis, - a 
condition which existed at the time of the operation, 
but with no septic peritonitis. 
In all these cases, before and after operation, micro- 
scopical examinations of portions of the uterus were 
made by Dr. Whituey or by Dr. Gannett. There 
could be no question, in any of them, as to the malig- 
nant nature of the disease. In only one of them has 
there been any secondary deposit. This was a case of 
malignant medullary cancer, in which the broad liga- 
ments and the uterine peritoneal investment were 
all affected by the disease. In this case there has been 
return, not locally, but at the meatus urinarius, a 
spot entirely distinct and separate. I doubt if the dis- 7 
ease had not become systemic, as stomachic troubles 
which have ensued would point to the same conclu- 
sion. 
My other cases are entirely free as yet, although, of 
course, the time is very short. Still, it is very satis- 
factory to realize that we have in this operation a 
chance of giving some assistance to those desperate 
cafies where a woman is bleeding, is rendered uncom- 
fortable and disgusting from the presence of a slough- 
ing mass, and which would not be undertaken to be 
cured by any other means. The Trendelenburg pos- 
ture is one which gives the greatest advantage in ma- 
nipulations in the pelvis for the removal of growths 
of all kinds, with the possible exception of large ova- 
rian tumors, in which it is unnecessary. 
In those cases where we have to deal with adhe- 
sions, in which we deal with fibroids, in which we deal 
with tumors involving the layers of the broad liga- 
ment, or of tumors or growths which are liable to 
bleed, it is invaluable; and the more one works with 
it, the more familiar he becomes with its possibilities, 
the more reluctant he will be to abandon it for the old 
method with the shorter incision, and the greater 
dangers from loss of blood, tearing of the intestines, 
or manipulation of the intestines. I know no disad- 
vantages except the one of a longer abdominal opening. 
The patient certainly looks extremely livid, but circu- 
lation is unimpaired. I have never seen an after re- 
sult which I felt to be unfavorable, due in any way to 
a prolonged operation in this posture; and one of 
mine, that was the first one, lasted nearly three hours. 
As Dr. Krug of New York has well said in explain- 
ing this position, you not only can feel and have all 
the advantage of your tactile ability, but more than 
all you have in addition to that, the opportunity of 
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