*A SUCCESSFUL VAGINAL HYSTERECTOMY FOR CARCINOMA UTERI. 
BY WILLIAM H. WATHEN, M. D, 
LOUISVILLE, KY. 
FROM THE TRANSACTIONS OF THE SOUTHERN SURGTeffE AND GYNECOLOGICAL SOCKEW. 
I had written a paper on ‘ ‘ Hysterectomy for Ma- 
lignant Diseases of the Uterus,” to read before the 
Southern Surgical and Gynecological Society in 
September, but after the meeting was deferred to 
December I read the paper before the American As- 
sociation of Obstetricians and Gynecologists at the 
meeting of the Congress of Physicians and Surgeons 
in Washington. I again find my name in the new 
program to report upon the same subject. It would 
not be courteous to the members of this association 
for me to read that paper again, for an extended 
abstract has been published in many of the medical 
journals in different sections of the country. 
But that I may in a degree fulfill my promise, I 
have concluded to report a successful vaginal hys- 
terectomy which I did in October, and to make 
some remarks upon the improved technique of the 
operation, especially upon that part of the details 
relating to hemostasis. I operated in the fore- 
noon of October 9th, at the Norton Infirmary, of 
Louisville, on Mrs. B. A., thirty-four years old, of 
Irish descent, and a mother of five children. When 
she consulted me, about the xst of August, she was 
suffering with nearly constant bleeding, the blood 
being mixed with offensive matter. Her digestive 
and assimilative functions were not good, and she 
was badly nourished. She was losing flesh rapidly, 
and her general appearance indicated approaching 
cachexia. 
I concluded from the history she gave me of her 
trouble that the disease began from twelve to 
eighteen months before I saw her. I found carci- 
noma of the cervix uteri extending up the endome- 
trium, but not involving the vagina or any of the 
uterine adnexa. The uterus was in normal position 
and perfectly movable, and no enlargement of pelvic 
or other glands could be detected. I did not believe 
all the disease could be removed except by total 
extirpation of the uterus, and advised her to have 
the operation done as soon as I could succeed in 
temporarily improving her local and general condi- 
tion. She lost but little more blood, and by the 1st 
of October looked and felt much better, and there 
was hardly any further extension of the cancer. 
She was prepared for the operation by being well 
purged, carefully bathed, and the vagina washed 
out with two gallons of hot water. The hair was 
cut from her pubes, and the parts well washed with 
ether and a 1-2000 solution of bichloride of mercury. 
The instruments, sponges, etc., were prepared with 
all the aseptic care that should govern us in doing 
successful abdominal surgery. I was assisted in the 
operation by Drs. H. H. Grant, J. B. Marvin, J. M. 
Matthews, H. Orendorf and F. C. Simpson. The 
water was boiled and the instruments and sponges 
were put by the nurse in weak carbolic acid solu- 
tion. Chloroform was administered and the opera- 
tion done after the following fashion : 
The woman was put in the exaggerated lithotomy 
position, and the neck of the uterus exposed by a 
Sims’ speculum and retractors, and drawn to the 
vulva with a heavy vulsellum forceps. The vagina 
was cut away from the cervix about one-fourth of an 
inch from its attachment, and two or three small, 
bleeding arteries secured by catch forceps. Further 
dissections posteriorly and anteriorly were made with 
the finger. The pouch of Douglas was first opened 
and all posterior attachments of the uterus rapidly 
separated. Then the uterus was carefully dissected 
from the bladder, great caution being observed to 
prevent wounding this organ or the uterus. Finally, 
all that held the uterus in position had been divided 
except the folds of the broad ligaments. The index 
finger was now hooked well over the left ligament, 
and it was secured at a distance from the uterus by 
a catch forceps of my device, which I here show you.f 
The right ligament was clamped in the same way. 
Both ligaments were then divided with the scissors 
near the clamps, and the uterus, ovaries and tubes 
were pulled away through the vulva. 
The uterus was not inverted, and was removed in 
just twenty minutes. To prevent the possibility of 
hemorrhage, all bleeding surfaces or points were 
caught in catch forceps, so that when the operation 
was done eight pairs were left in the vagina. 
She did not lose more than one or two ounces of 
blood during the operation, and none after it. The 
small forceps were removed in twenty-eight hours 
and the two large ones, clamping the broad liga- 
ments, were removed in fifty-two hours. A small 
pledget ot sublimated gauze was introduced into the 
vagina to hold the forceps apart and to aid drainage, 
*This is probably the first vaginal hysterectomy for cancer performed south of the Ohio river. 
f [A vaginal hysterectomy forceps should be so constructed that it may include in its blades the entire broad ligament with equal pressure, 
and absolutely control hemorrhage, but it should be as small as is consistent with the purpose which it is intended to serve. Some of the heavy 
instruments devised cause too much local irritation and sloughing of the vagina and vulva, and some of the smaller ones do not insure per- 
fect hemostasis. Appreciating these defects, I had the 
Messrs. Tiemann & Co., one year ago, make a forceps that I 
think overcomes these objectionable features. The forceps 
is light, compresses with equal force at each end of the 
blades, and will include the ligaments so firmly that the 
danger of secondary hemorrhage is wholly eliminated. The 
blades are deeply grooved in the center so that they are 
buried in the broad ligaments with less pressure than is nec- 
essary with the ordinary forceps. This insures permanent fix- 
ation, thereby absolutely controlling hemorrhage.]—Extract 
from the New York Medical Journal. 
"g.tiemann&co. 2 
SUCCESSFUL VAGINAL HYSTERECTOMY FOR CARCINOMA UTERI. 
and the vulva was well covered with absorbent cotton 
and a T bandage applied. No sutures were used to 
control hemorrhage or to unite surfaces, and the 
vaginal vault was left open. The gauze was removed 
from the vagina when the small forceps were taken 
off, and it was subsequently used only as a dressing 
over the vulva. The discharge of necrosed matter 
which had been destroyed by the forceps was rather 
profuse and offensive for a few days, but after a 
week it had nearly ceased and was not at all offen- 
sive in odor. No vaginal washes were used, but the 
dressing was removed twice daily, and the external 
parts carefully cleansed. She was allowed to lie on 
her back or sides, as she preferred, and her water 
drawn for one week. Her bowels were moved on 
the sixth day with sulphate of magnesia, and moved 
every day or every second day afterward. She had 
beef peptonoids, beef tea and mutton broth for three 
or four days ; then she began to take milk and a lit- 
tle solid food, each day increasing the quantity, and 
after the eighth day she took house diet. She suf- 
fered two days from the presence of the forceps, and 
for two days more from an irritability of the bladder. 
She was given during this suffering one-sixth of a 
grain of morphine two or three times daily. Her 
pulse, after the operation and during the first day, 
was sixty beats per minute. It then ranged from 
sixty to ninety, seldom getting above seventy-five. 
Her temperature reached nearly ioi° on the second 
day, probably caused by the local annoyance and 
pain from the clamps. It then ranged from 98° to 
ioo°. At no time was there any shock or sepsis, 
and she made an uninterrupted recovery. She was 
out of the bed on the fifteenth day, and left the 
Infirmary on the nineteenth day. 
The vaginal vault had perfectly united at the end 
of one week. I have examined her several times 
since she left th« Infirmary, and can detect no evi- 
dence of any return of the disease. Her general 
condition and appearance and all her functions had 
improved about twenty-five per cent, at the end of 
the second week, and she has continued to get better ; 
in fact, she looks and feels perfectly well, and is 
going out on the street and is attending to her do- 
mestic duties. 
I interdicted sexual intercourse for three months, 
but probably this precaution is not entirely neces- 
sary, as there has been neither pain nor tenderness 
on pressure, after the third week, in the vagina or 
in the pelvic or abdominal cavities. 
A careful microscopic examination of the speci- 
men removed was made by Dr. Simon Flexner, who 
reports as follows : 
Louisville, Ky., November 3, 18S8. 
My Dear Doctor : Herewith I beg leave to submit a 
report on the examination of a specimen handed to me. 
The specimen consisted of uterus, tubes and ovaries just 
removed. The uterus had suffered marked change in con- 
figuration. The cervix was changed most and was the seat 
of evident degenerative change. 
The degenerative process could be traced by the unaided 
eye through the cervix and about one-half the length of the 
fundus, where the tissue had a more healthy appearance. 
This limitation of degenerative process was subsequently 
confirmed by microscopical examination, as will appear. 
The tubes were apparently in a healthy condition, and the 
ovaries presented no abnormal features, save a few cysts. 
On microscopical examination the growth involving the 
cervix proved to be adeno-carcinoma; as before indicated, 
the new process extending into the body of the uterus dis- 
appearing about its center. In the mucous membrane of 
this portion there is considerable hyperplasia of the nor- 
mally present spindle shells, and foci of round cells are 
occasionally observable. The glandular structure, however, 
appeared quite normal. Microscopical examinations of one 
ovary, at the point where it is attached to the tube, shows 
no degenerative change. Some connective tissue prolifera- 
tion had taken place. Beyond this I could observe no 
change. 
The tubes were not examined microscopically. 
Pieces from which sections were made were immediately 
removed and hardened in alcohol. Very truly, 
Simon Flexner. 
Asepsis or perfect surgical cleanliness should be 
enforced in every detail of the operation. Weak 
solutions of disinfectants may be used, but I doubt 
their efficacy, and strong solutions are positively 
poisonous. I believe the success of vaginal hyster- 
ectomy depends largely upon absolute surgical clean- 
liness, rapidity in operating and a perfect hemostasis. 
When the operation is prolonged and the woman is 
kept for one or more hours under the influence of an 
anesthetic, or loses muffi blood, she is in relatively 
greater danger of death from shock or sepsis. By 
the use’of clamps to control hemorrhage, the tech- 
nique of the operation is so much simplified and 
improved that the uterus, etc., can be removed in 
from ten to twenty minutes, and the loss of blood is 
no longer an important factor. The clamps also 
afford an excellent means of drainage and do away 
with the necessity of a drainage tube. But if we 
follow the technique of Schroeder, Martin and others, 
and use sutures to control hemorrhage and to unite 
the vaginal and peritoneal surfaces, or to close the 
vaginal vault, it will require from one to two hours 
to complete the operation, and the hemostasis is not 
so perfect. Results have shown that it is best not 
to close the vaginal opening, and experience has 
demonstrated that the supposed dangers resulting 
from intestinal or omental protrusion in the vagina 
are mostly imaginary; at least they are reduced to 
a minimum. 
I believe that the mortality in vaginal hysterec- 
tomy can be reduced as low as that in ovariotomy, 
but I beg to repeat what I have said at another time, 
“ that it is positively criminal for any one to attempt 
to extirpate a cancerous uterus or to do pelvic or 
abdominal surgery until he learns the anatomy, 
physiology and pathology of the pelvic and abdomi- 
nal structures, and knows how to make a correct 
diagnosis where it is possible to do so. He should 
also know the general principles and the details of 
the most approved technique for such operations.” 
Nor should the uterus be removed if there is any 
evidence of cancerous cachexia, or if, in a careful 
physical examination, any structure outside of the 
uterus in the pelvic cavity is found to be infected. 
A microscopical examination of a part of removed 
tissue by an experienced microscopist and patholo- 
gist may aid us very much in diagnosticating cancer 
of the uterus in its incipiency, when we may expect 
the best immediate and subsequent results from 
vaginal hysterectomy.* 
*Ten months after the operation there is no return of the cancer, 
and the woman weigh's ten pounds more than at any time since her 
marriage, and feels perfectly well.