Studies and Methods in Supra- 
Pubic Hysterectomy. 
BY JOSEPH EASTMAN, M.D., LE.D., 
OF INDIANAPOLIS, IND. 
Reprinted from the North American Practitioner. The North American Practitioner. 
SEPTEMBER, 1893. 
STUDIES AND METHODS IN SUPRA-PUBIC 
HYSTERECTOMY A 
By Joseph Eastman, M.D., LL.D. 
Of Indianapolis, Ind. 
The surgical triumphs of the century have done more to bless 
humanity than those of all preceding ages. Weare anxious to include 
within its last decade an unchallenged method of removing fibroid 
tumors; a method that will be equally successful in the hands of the 
many as the few. My practical studies in supra-pubic hysterectomy 
began on Feb. 3, 1887. At that time the question open for discussion 
was, “Shall it be the extra-or intra-peritoneal treatment of the pedicle?’ 
Leaving constricted muscular tissues within the abdomen has been 
abandoned by nearly all. And now the only question to be settled is, 
“Shall it be intra-pelvic or abdominal fixation?’’ The extra-peritoneal 
method was understood to be the fixation of the stump of the tumor 
in the lower angle of the abdominal wound. Its ablest and most suc- 
cessful champion was Ur. Bantock, of London. After what I consid- 
ered mature deliberation as to which one of these methods I would 
adopt in my first operation, utilizing what little anatomical, pathologi- 
cal, mechanical and surgical sense' I could command, I was loth to 
accept either method as satisfactory to me. I was inclined, however, 
toward the so-called “Shroeder method, ” but did not believe it was 
surgical wisdom to leave constricted muscular tissue within the peri- 
toneal cavity. I believed this could be shut off from the peritoneal 
cavity and by cutting out all but the vaginal portion of the cervix I 
could have free drainage by the vagina from every point where liga- 
tures had constricted muscular tissue. 
I prepared myself and proceeded to operate in the following 
manner: 
Having made the usual incision extending to the umbilicus, the 
*A lecture delivered to the Post-Graduate Medical School of Chicago, July 17, 1893. 388 
tumor turned upward and out of the abdomen, the broad ligaments 
were clamped and ligated with cobbler’s stitch and separated with a 
cautery; the pedicle was clamped with Eastman’s large temporary 
clamp. A strong elastic ligature was then thrown around the pedicle 
nearly as low as the vaginal attachment and then it was severed between 
the clamp and the ligature. Dissecting off the peritoneum and turning 
it down as we would the skin flap in an amputation before dealing with 
SUPRA-PUBIC HYSTERECTOMY. 
the muscles and blood vessels I then severed the mass above the 
elastic ligature. A conical-shaped piece of tissue was cut out of the 
stump, the apex pointing toward the os, the base directed upwards and 
outwards toward the serous membrane. 
A cautery iron of blue heat was three times passed through the SUPRA-PUBIC HYSTERECTOMV. 
389 
cervical canal from above downward for the purpose of destroying 
mucous membrane and also to assist in draining from the interior of 
the stump. A dressing forceps was passed after the cautery by the 
aid of which a rubber tube as large as my little finger was dragged up 
to within a half inch of the free peritoneal surface. All the muscular 
tissue of the stump was constricted by a sort of cobbler’s stitch which 
did not include the peritoneal flaps but kept three-fourths of an inch 
from the peritoneal margin. This constriction of the muscular tissue 
by the cobbler’s stitch brought every part of the muscular tissue in 
close proximity to the end of my rubber drainage tube. Stitches 
were cut short. The peritoneal flaps were brought together by 
Lembert’s suture. 
The peritoneal cavity was cleansed, and a glass drainage tube 
placed down into Douglas’s cul-de-sac. The abdominal wound was 
closed with silk sutures. There was Tittle shock and the patient made 
a satisfactory recovery. 
In the comment which I made in publishing this case in the Trans- 
actions of the State Medical Society for 1887, I said, “It would seem 
from this report that I used Shrceder’s method with certain additions. 
One of the facts which I should have commented on was that this 
differed from Shrceder’s method in a most essential particular; namely, 
it was not an intra-peritoneal method at all. Every portion of the 
stump had drainage into the vagina and was absolutely shut off from 
the peritoneal cavity. I did state, however, that I believed I would 
use the same method again, including drainage, not only because the 
result was good in this case, but because I believed where it could be 
done it was the ideal method. After five hundred abdominal sections 
for different diseases I am convinced that with slight modifications 
this method, anatomically considered at least, approximates ideality 
as near as any with which I am familiar.* 
Dr. Marcy, of Boston, does a similar operation, except that he uses 
his favorite buried suture of kangaroo tendon. Dr. Kelly, of Balti 
more, has step by step reached a similar operation. Dr. Baer, of 
Philadelphia, ties the uterine arteries through the broad ligaments, 
making no attempt to drain the sac or close the pocket he must 
inevitably have.f 
I have had two cases where nodular masses low down on the cervix 
so hid the arteries that they could not be reached except by going 
down between the folds of the broad ligament, and three cases where 
after ligating the arteries, probably on the uterine side of the circular 
artery, there were a half dozen abnormally enlarged spurting arterial 
twigs to be ligated in the peri-cervical tissue. Reaching the artery 
further from the uterus endangers the ureters. (See cut from Pozzi.) 
*1 have made this operation twenty-seven times. 
tlf Dr. Baer’s operation is faultless his descriptions ar* faulty. Dr. Mann, of Buffalo, attempting 
to follow his descriptions had two deaths. Others to my knowledge have had similar experiences. 390 
SUPRA-PUBIC HYSTERECTOMY. 
ANATOMY. 
This drawing is taken from Pozzi (Volume I, page 361). U represents 
the uterus; AU the uterine arteries; V a section of the bladder drawn 
forwards; Ur. ureters passing behind the uterine arteries diverging as 
they ascend to the side of the pelvis; C the cervix uteri as seen 
through a transverse incision of the anterior vaginal cul-de-sac. “The 
uterine artery springs from the anterior division of the internal iliac 
and passes downward and inward toward the cervix uteri. It then 
passes upward between the layers of the broad ligament by the sjde 
Cut No. 2. 
of the uterus in an exceedingly tortuous manner to anastomose with 
the lowergbranch of the ovarian. Branches pass from it into the sub- 
stance of the uterus. These are the coiling arteries of the uterus. 
The vaginal arteries usually spring immediately from the anterior 
deviation of the internal iliac artery, but sometimes arise from the 
uterine or middle hemorrhoids. The special branch of the uterine 
artery to the cervix joins with its fellow at the isthmus to form the 
circular artery, and with those of the vagina to form the azygos artery 
of the vagina.” SUPRA-PUBIC HYSTERECTOMY. 
391 
COMMENT ON METHOD. 
The ideal operation would seem to be one which patterns after the 
amputation of the thigh. After tying the broad ligaments and cutting 
the threads short, suitable flaps are made of peritoneum high up on 
the tumor. I then ligate the arteries within the folds of the broad 
ligament, also every other bleeding point, because if the arteries have 
not been ligated beyond the region of the circular branch there will 
still b‘e hemorrhage when the cervix is severed. (See cut No. 2.) 
The ligatures may be kangaroo tendon, silk-worm gut or even silk. 
They may be cut short, the cervix removed down to within one-half 
to three-fourths inch of the external os, the cervix freely dilated and 
packed with gauze, or a small drainage tube may be used. The peri- 
toneal flaps are then brought over by continuous or interrupted suture, 
being careful that there is complete sero-serous approximation. To 
ligate the uterine artery so as to have a bloodless severing of the 
uterine cervix we must either go near the ureter at a point before the 
circular artery of the cervix is given off (See cut No. 2) or if we 
include the circular with the uterine artery proper we have included a 
considerable amount of connective tissue in our ligature. And here is 
one of the sources of danger in this operation—the disturbance of the 
connective tissue at the side of the uterus, which, as every anatomist 
knows., is richly supplied with lymphatic glands so that the least atom 
of aseptic material is rapidly carrried into the circulation. I would by 
preference, as in my first case in February, 1887, expose the uterine 
artery as much as possible between the folds of the broad ligament 
before ligating it or if the artery were not readily found, cut boldly 
through the cervix one side at a time. When the arteries spurt, I 
would control the hemorrhage with the finger, until it could be seized 
with the artery forceps and ligate the bare artery with no connective 
tissue as the surgeon seeks to do while amputating a limb. 
COMMENT. 
This and all other kinds of operations for fibroid tumors require a 
thorough mastery of the great surgical principles, together with a 
practical knowledge of anatomy. At the same time one must be 
capable of detecting the dislocations of arteries and ureters produced 
by the development of nodular masses low down in the broad 
ligaments. 
Dr. Mann, of Buffalo, N. Y., in a recent paper read before the 
American Gynecological Society, says that since the reading of the 
papers of Drs. Polk and Baer, last year, there has been a tendency to 
give up the clamp and try intra-peritoneal methods. To my knowledge 
a half dozen operators gave up the clamp four or five years ago and SUPRA-PUBIC HYSTERECTOMY. 
392 
have been trying to perfect some better method, but so far as my 
reading leads me to judge, none of them have tried intra-peritoneal 
methods. I say this because I want it distinctly understood that while 
this method which I used in ’87 is intra-pelvic it is as much extra- 
peritoneal as the method by the serre-neud or the fixation of the 
pedicle in the • vagina so successfully practiced by Dr. Byford of 
Chicago. 
In November, 1888, while in consultation with a professional friend, 
from whose wife I was about to remove a large fibroid tumor, he sug- 
gested that he believed abdominal fixation of the pedicle would give 
the best results. In order that he should share in the responsibity I 
accepted his suggestion. This was my first operation by this method 
and turned out to be one calculated to try my skill in manufacturing a 
pedicle. Both tubes were eight inches in length and one and one-half 
inches in diameter. Each tube contained one-half teacup full of pus. 
d ubes and ovaries were in one common mass in Douglas’s pouch. The 
tumor weighed fifteen pounds. I manufactured a satisfactory pedicle, 
fixed it in the abdominal wound, and the patient made an excellent 
recovery. (See cut No. 3.) 
I made a number of operations by this method including one where 
the diameter of the tumor, after tying off broad ligaments and ovaries 
where T began to make a pedicle, was six inches. Dissecting down 
the peritoneum and lifting up the pedicle enabled me to get a satis- 
factory fixation of the same in the abdominal wound. (Cut No. 3^.) 
I speak of this to disarm the criticism of those who constantly 
insist that the operators, dissatisfied with abdominal fixation do not 
know how to manufacture a pedicle. I have now fixed pedicle in the 
abdominal wound sixteen times. In August, 1889, I encountered a 
case with nodular masses, partially gangrenous, deeply imbedded in 
the broad ligament. I eneucleated them, manufactured my pedicle, 
and brought as I believed, most of the pockets from which I had 
eneucleated the nodules well up to my serre-neud, but could not do so 
satisfactorily. This patient died and post-mortem examination showed 
that those pockets below the serre-neud had been the source of infec- 
tion and septicaemia. This case impressed my mind with the fact that 
this method was not applicable to all cases. 
ABDOMINAL FIXATION METHOD. 
COMMENT. 
I concede that able operators are having good results with the 
serre-neud, and by making a pedicle for every tumor whether it should 
have one or not. I have had good results with this method and bad 
results which I could have avoided with a better one I might use a SUPRA-PUBIC HYSTERECTOMY. 
393 
wire in a case demanding it. I have a serre-neud, tried and trusted, 
always in my operating room. The method, however, contains~two 
erroneous ideas. First, it is unsurgical; as much so as would be the 
practice of putting an ecraseur round all the muscles, arteries and 
bones in performing amputation of a thigh instead of making flaps out 
of the muscles and skin, ligating the arteries separately, sawing off the 
Cut No. 3. 
Cut No. 3y2. 
bones and bringing the flaps together, using suitable drainage. The 
second is the encumbering the abdominal wound with a pedicle which 
in most cases can just as well, even better, be dropped. 
In a conversation with Dr. Bantock, in his office in London, I learned 
that this distinguished advocate of fastening the pedicle in the lower 
angle of the wound had, like myself, found cases of multinodular 
fibromata where the new growth filled the pelvis, displacing the broad SUPRA-PUBIC HYSTERECTOMY. 
394 
ligaments and disorganizing the uterine cervix to such an extent that 
no pedicle could be formed. He deals with these cases by eneuclea- 
tion, packing with gauze and draining through the abdominal wound 
after having fastened the serous covering of the pelvis to the serous 
lining of the abdominal wall. 
In my next case I was determined to leave no pedicle to become 
gangrenous, to slough, to bleed and to furnish septic material to con- 
taminate the peritoneal cavity. Having at that time cut and tied my 
way up around the cervix in thirteen extirpations of the cancerous 
uterus, I was confident that I could find my way down, avoiding ureters 
and bladder after tying off broad ligaments. I used a Simon’s retrac- 
tor in the vagina and lifted the cervix by elevating the floor of Doug- 
las’s cul-de-sac. From my familiarity with the parts gained in the 
cancer operations I found little difficulty in tying, cutting and remov- 
ing the cervix entire, then bringing the ligatures, which had been left 
eight inches long, down through the wound in the vagina. I had 
complete capillary drainage and also added a drainage tube to make 
sure of a good out-flow of all fluids used in washing the peritoneal 
cavity. This patient made such an ideal recovery that I was induced 
to still further perfect the method by having a hysterectomy staff 
made, which is here shown. (See cuts Nos. 4 and 5.) 
One of the main objects in the use of the staff is to so elevate the 
cervix and Douglas’s pouch that the operation can be done more 
quickly and safely than can otherwise be. It gives us an assurance of 
what we are doing and how we are doing it that cannot alone be given 
by the Trendelenberg position. For another reason any method of 
operating which can be completed in the shortest space of time has 
many advantages. I had some eight consecutive recoveries by the 
abdominal fixation method when I turned my attention toward per- 
fecting the technique of what I hoped was a better method. After 
having such instruments made as I believed would enable me to do the 
operation as quickly if not more so, and having proven to my satisfac- 
tion by eight consecutive recoveries that this method was as success- 
ful as the other, I published the same in the Indiana Medical Journal. 
The article was translated into German and published in the “Memor- 
abilien" Zeitschrift fur rationelle praktische Aerzte, July, 1890. I was so 
elated with my results that 1 said to Dr. Bantock, of London, that I 
hoped soon to be able to say that we could remove fibroid tumors with 
the same low rate of mortality that followed our work in ovariotomy. 
He replied, “It can never be done. The anatomical and pathological 
conditions are essentially different.’’ A little later by invitation of Dr. 
August Martin, I demonstrated this method of operating to the 
TOTAL EXTIRPATION METHOD. SUPRA-PUBIC HYSTERECTOMY. 
395 
Gynecological Section of the International Medical Congress in Berlin. 
Prof. Krobak, of Vienna, was present. After the demonstration I 
gave my staff to Dr. Martin. Since this, Prof. Krobak, of Vienna, is 
using a similar staff, and his method of operating as described by Dr. 
Zinke, of Cincinnati, is precisely the same in all its essential principles. 
His results have been remarkably good.\ 
Cut No. 4. 
At a meeting of the Southern Gynecological Society at Richmond, 
Va., Dr. Marcy, of Boston, Dr. Ross, of Toronto, Canada, and Dr. 
Kelly, of Baltimore, and others, spoke favorably of my endeavors 
toward the perfection of technique that could be as rapidly carried 
out as any other method. Each had suggested some little modifica- 
tion or improvement. This encouraged me in the belief that these 
gentlemen were thinking in the same direction; their minds not of the 
X Dr. Rufus B. Hall, of Cincinnati, has had seven consecutive recoveries by this method. Dr. C. A. 
L. Reed, Dr. Ross, of Toronto, Dr. Rohe, of Baltimore, and others, speak favorably of this method. 396 
SUPRA-PUBIC H YSTERE CTOM V. 
mimic, too prejudiced against new thought to leave the old paths, but 
capable of original thought and action along the lines of surgical pro- 
gress which always converge towards the perfection of technique 
and simplicity in operating. The greatest objection to total extirpa- 
tion of the cervix is the possibility of vaginal infection, notwithstand- 
ing we may have used every precaution in rendering this tube aseptic. 
Our manipulations of the tumor sometimes cause to pour out a 
quantity of poisonous material through the cervix into the vagina 
to come in contract with the finger or ligature while stitching 
around the cervix. This may be avoided by packing the cervix with 
iodoform gauze and closing os with suture before opening the 
abdomen. 
I have performed hysterectomy, removing the cervix entire sixty- 
seven times, and my results so far have been best by this method. 
VAGINAL DRAINAGE. 
At times I have been dissatisfied with the removal of the entire 
cervix and vaginal drainage mostly because of the great dangers of 
infection from the vagina. I am now fairly well satisfied that my 
original way of using a glass tube so constructed at the upper end as 
to prevent the possibility of its becoming closed, and with no 
openings of the tube below the point where it is constricted by the 
vaginal vault, is a good method of drainage. This enables us to 
pour large quantities of hot water into the peritoneal cavity, warm 
up the intestines which are often beginning to be distended with gas 
from exposure to the air, with the assurance that the water will be 
freely discharged through the large tube fixed in the vaginal wound. 
I believe it almost criminal to publish to the world that drainage can 
be dispensed with in supra-pubic hysterectomy. While it may be done 
when the abdomen is only open for a short time, someone else of less 
experience leaves the chilly bowels following a tedious operation with- 
out their being warmed up by the wash-out; serum is poured out into 
the peritoneal cavity, the chilled peritoneal surface not being able to 
absorb it again, and serious consequences ensue. 
This I believe to be a vital point. Many, many deaths have occurred, 
the operator faulting the method used in treating the pedicle when the 
fault was in the length of time consumed in the operation, and not 
counteracting its direful results upon the peritoneum by thorough 
flushing with hot water in the peritoneal cavity. These operations 
are the most taking of any I know of on the strength of the operator. 
Any operation which uses up the strength of the operator has a prob- 
ability of having a similar effect upon the patient. SUPRA-PUBIC HYSTERE CTO MY. 
397 
AFTER TREATMENT. 
In no other abdominal operation is it so highly important to carry 
out the very best methods in the after treatment of the case. There 
has been a great deal of discussion whether or not to give opiates to 
relieve the pain in the abdomen following cceliotomy. In my last 
hundred cases I have been acting upon the idea that this pain was due 
to distension of the intestines with gas (except what came from the 
constriction of the serre-neud in cases where it was used). I had 
often seen exposed intestines begin to show that gas was accumulat- 
ing even before the abdomen was closed. This confirmed my belief 
that nearly all the pain following abdominal section was due to gas in 
the intestines. It has been suggested that to relieve this, saline pur- 
gatives should be given as soon as the stomach will retain them and in 
that way relieve the pain. Following the shock of hysterectomy 
there is nothing which has such a tonic effect upon the nerves dis 
Cut No. 5. SUPRA-PUBIC HYSTERECTOMY. 
398 
tributed to the intestinal tract as nux vomica and the preparations of 
strychnia. 
Prof. Hare, of Philadelphia, did a great service to the profession in 
his address before the American Medical Association, at the last 
meeting, by calling attention to the large dose of strychnia borne 
with great advantage in cases of surgical shock, illustrating that as 
large doses of morphine are counteracted by intense pain, so the 
effect of large doses of strychnia are counteracted by the condition of 
the nerve cells during shock. I give strychnia or nux vomica in ordin- 
ary doses previous to all abdominal operations, especially cases of 
supra-pubic hysterectomy. Immediately after the operation I begin 
with five drops of Squibb’s tincture of nux vomica, having it repeated 
every hour urfless there should be free evacuation from the bowels 
accompanied by a considerable amount of flatus. This is aided by 
large enemata of salt water repeated at intervals of four hours. Where 
these salt water enemata are retained I think some of it is absorbed and 
has a decided beneficial effect in priming the pumps of secretion, 
excretion and elimination. With the nux vomica and the enema 
the bowels are frequently moved during the first twelve hours. 
At all events, the nux vomica needs only to be supplemented with a 
small amount of saline cathartics, inasmuch as we have, by the nux 
vomica, counteracted at the very beginning the tendency to intestinal 
paresis and maintain that effect by continuing the same. 
I have given the advantages and disadvantages of three methods 
for the reason that they are the only methods with which I have had 
any considerable experience. 
The sum total of individual experiences will utimately reach the 
truth. From my studies in this direction I would draw the the follow- 
ing conclusions: First. That in treating sub-serous tumors where a 
pedicle.containing little muscular tissue can be made above the uterus, 
leaving ovaries and tubes undisturbed, the pedicle may be dropped as 
in ovariotomy. Second. Where a pedicle contains so much muscular 
tissue that ligatures cannot be incapsulated but may be cast off, it is 
bad surgery to leave such pedicle within the peritoneal cavity. Third. 
Where the neck of the uterus remains small, abdomen not too fat 
after the ovaries and tubes have been tied off, the pedicle may be 
fastened in the lower angle of the wound and give satisfactory results. 
Fourth. The intra-pelvic method which I have described and first used 
in '87, or some of its modifications by Marcy, Kelly, Baer and others, 
will in the hands of expert operators be a safe method. Fifth. Where 
the neck of the uterus is so deformed by nodular growths that it is 
inexpedient to make a pedicle out of the same, where cavities from 
which nodular masses have been eneucleated or pus cavities cannot 
be drained into the vagina, where the abdomen is very fat, extirpation SUPRA-PUBIC HYSTEREC1OMY. 
399 
according to the method which I have described and the technique of 
which I have perfected, including the use of my hysterectomy staff 
gives results to me as satisfactory as I have been able to obtain in any 
surgical operation, and would seem to leave little to be desired by way 
of treating a class of fibroids heretofore defying successful manage- 
ment by our best surgical methods. 
My experience with fibroid tumors has been large enough to in- 
clude some very difficult cases (See cuts Nos. 6, 7, 8.) 
These cuts represent illustrative cases. In the one (See cut No. 
6) the tumor was entirely intra-ligamentous, completely filling the 
pelvis, extending much below the lowest plane of the external os. 
The second represents a pendulous fibroid weighing sixty pounds. 
These cuts are presented for the purpose of asking how one could 
first ligate the uterine arteries according to Baer’s suggestion or how 
a pedicle could reasonably be made and fixed in the lower angle of 
the abdominal wound. Cut No. 8 represents an immense pus tube 
and ureter emptying its contents into it and thus making a small 
bladder or urinary reservoir. Is it possible that these ugly tumors 
are only to be found in the rough and rowdy West, and that in the 
smoother society of our Eastern cities all the tumors have small 
necks and arteries easily reached by ligature? Until some of these 
questions are answered I think some of us are justified in withholding 
our per cent, of recoveries. 
There are two kinds of operators. The one is so impressed with the 
deaths which have followed his work that his large list of recoveries 
to him seem almost forgotten. The other is so impressed with his 
list of recoveries that they become the one glaring feature in nearly 
all his reports, and he seems to have forgotten his list of deaths. 
I am not anxious that my name shall be attached to any par- 
ticular method. I would prefer to be a man with no method, 
submitting to the law which the peculiarities of each case shall 
make. I would not care to contribute to the perfection of a 
method which could only be successful in the hands of a few. I am 
sincerely desirous of doing all in my power toward the perfection 
of such methods as shall be successful in the hands of the many. 
I am encouraged in my belief that when the teachings shall have 
become obsolete that fibroid tumors are comparatively free from 
danger, give little or no trouble after the menopause, we shall 
deal with small tumors by removal of the uterine appendages and 
with larger ones by surgical methods, and have as low rate of mor- 
tality as we now have in removing ovarian tumors. We cannot hope 
to reach this much desired Mecca in our surgical pilgrimage if we 
stick to some buckram rule in operating, ignoring the fact that the Cut No. 7. Cut No. 6. 
Cut No. S. SUPRA-PUBIC HYSTERE CTOMY. 
402 
peculiarities of the tumor or pedicle should determine our surgical 
methods of treating the same. 
Fortunate is he who can comprehend the anatomical and patho- 
logical bearings in a given case, use good judgment in selecting his 
method, at every step of the operation, and in each and every 
emergency. The successful hysterectomist is both born and made, 
and the surgical type of a man is not to be found thirteen times in 
a dozen.