[Reprint from Proceedings of the Michigan State Medical Society, 1894.] 
SUPRA-PUBIC HYSTERECTOMY BY ENUCLEA- 
TION OF TUMOR AND UTERUS, 
INCLUDING CERVIX. 
JOSEPH EASTMAN, M. D., LL. D., 
In«tlUH!l foils, Ind. 
PREFATORIAL REMARKS. 
Ladies and Gentlemen .-It gives me great pleasure to meet 
with the profession of my adjoining State, and in the remarks 
I shall make I hope you will bear with me and excuse the fre- 
quency of the pronoun, I. A certain amout of ego seems 
necessary in discussing some questions of original work. 
The lines of surgical progression converge toward the 
simplification of technique in operating. The simplicity of a 
surgical operation or instrument is the measure of its success. 
That all men seeking to establish some originality in operating 
have not the anatomical knowledge, mechanical genius, and sur- 
gical wisdom to solve the great problem of hysterectomy, is 
plainly evidenced in some of our recent text-books, in which 
illustrations can be seen of the operation in vaginal hysterec- 
tomy, with numerous forceps maintaining the broad ligaments 
nearly full width, so that their raw edges could infect or become 
adherent to intestines or omentum when the ligaments should 
be rounded with a strong ligature, brought down into the 
vagina, fixed extra-peritoneally by single clamp or ligature and 
the wound closed with as much precision as in coeliotomy. 
Other recent text-books may be cast aside as back numbers in 
so far as original contributions in infra, and supra-pubic hys- 
terectomy are concerned. On February 3, 1887, knowing full 
well that abdominal fixation of the pedicle in supra-pubic 
hysterectomy had at that time given the lowest rate of mor- 
tality, I decided not to operate in that way, but planned and 
executed an operation which in every essential feature was an 2 
STATE MEDICAL SOCIETY. 
extirpation of almost the entire cervix. A large cautery passed 
three times down through the cervix in reality destroyed a 
large portion of the atom of cervix I had left. A rubber 
drainage tube was inserted for vaginal drainage. Ever since 
the above mentioned date, I have been making every possible 
effort of which I was capable to perfect a method, and I am 
much pleased to state that the intense desire of my heart has 
been gratified. In a recent discussion in the New York 
fournal of Obstetrics and Gynecology, they speak of the opera- 
tion by Stimson, Krug, Baer, and myself, as if they were all 
operations of total ablation of the uterus. If these operations 
are to be considered, then the operation by Stimson, in Novem- 
ber, 1888, was antedated by my determination to secure some- 
thing better than the abdominal fixation of the pedicle, on 
February 3, 1887. 
It is not my purpose to occupy time in discussing questions 
of priority in making an operation which is not applicable to all 
shapes and forms of tumors, although the operation including 
the use of my hysterectomy staff, as I demonstrated it at the 
International Medical Congress in Berlin, has since been made 
many times by Krobak, of Vienna, and numerous American 
operators with great satisfaction, and while I have received 
many congratulatory letters from distinguished operators at 
the rapidity and definiteness of the operation made possible by 
the use of the staff, I have been working for the last three 
years to still further simplify and perfect the operation. So in 
February, 1887, in answering the question which came to my 
mind as to what to do with the pedicle in supra-pubic hys- 
terectomy, I decided to have none. The next problem to be 
solved was what to do with the broad ligaments and the liga- 
tures on them. In many operations, I answered this question by 
ligating the uterine arteries and with the same ligature includ- 
ing as much of the broad ligament as was safe to constrict, 
leaving these ligatures long and carrying them down and out 
the vagina, using gauze or drainage tube for drainage. 
I have been for several years endeavoring to reduce the 
number of ligatures and have made numerous dissections to 
determine the possibility of dispensing with the very difficult JOSEPH EASTMAN. 
3 
task, at times, of securing the uterine arteries. It is amusing 
to see published statements by different operators, they intimat- 
ing that they would always secure the uterine arteries in a cer- 
tain way, as if the broad ligaments were precisely the same 
length and the uterine arteries equally accessible, when they 
know full well that the broad ligaments are rarely ever alike in 
length, in breadth, in thickness, or in location, and that in some 
instances the uterine arteries could not be ligated at all. The 
theme nearest to my heart for the past eight years has been the 
perfection of the method of removing fibroid tumors which 
shall disregard the morphology of tumor, of broad ligament, and 
the anomalous distribution of uterine and ovarian arteries, one 
that shall be successful in the hands of the many as the few 
expert operators. 
Now, we are told in certain publications that the uterine 
arteries should be secured in a definite way. We are told in 
certain other publications that we can ligate the uterine arteries 
and arrest the growth of the tumor. 
A friend, in Chicago, cuts down and ties the ovarian arteries 
and the uterine arteries as well, and arrests the growth of the 
tumor. We are told that the abdominal fixation method fur- 
nishes the largest per cent, of recoveries, hence, that should be 
the method. I will challenge any expert operator to show me 
upon this specimen (exhibiting specimen"), how it would be pos- 
sible to make a pedicle here that you could fix in the lower 
angle of the wound. I challenge any expert operator to show 
me how he can reach the uterine arteries when I show you 
that the uterus is imbedded between these two nodular masses 
here as I hold it. I want to ask you, how are you going to 
ligate the uterine arteries with this mass at the side, or ligate 
this one with this mass already gangrenous, as I hold it in my 
hand. The tumor, however, was removed and removed satis- 
factorily. This mass you see here is already gangrenous, and 
it is very peculiar. 
The point I wish to make is, that in these cases the abdom- 
inal fixation method or the one in which the Philadelphia gen- 
tleman ligates the broad ligament, is impossible, nor do I 
believe the man lives who could have detected previous to STATE MEDICAL SOCIETY. 
4 
abdominal section that this portion of the tumor was gangren- 
ous and that the ligation of the uterine arteries or the use of 
electricity would not have been the thing to do. Nothing but 
an abdominal section would have diagnosticated the condition 
of that nodule, and in these cases the other methods are 
absolutely ruled out. 
It so happened that a week ago I encountered this tumor 
(exhibiting specimen). It thoroughly shows the tissue change, 
and in connection with this very thought I wish to say that we 
cannot know before opening the abdomen how much of the 
tumor is gangrenous, or how much is not. The upper portion 
of this growth was in an advanced stage of gangrene, the very 
small pedicle having failed to nourish it. It contained a poison- 
ous fluid at this point. The treatment of such a case by elec- 
tricity, ligating the uterine or ovarian arteries, would simply 
have meant death to the patient. When I locate, as I think I 
can here, the cavity of the uterus, I will simply ask you 
how you would fix a pedicle here. The cervix was obliterated 
in the tumor. No cervix could be felt in the vagina. It was 
completely disorganized by the nodular masses on either side. 
Suppose the extra-peritoneal method does give the largest per 
cent, of cures, and at present has got the best per cent, of 
recoveries, here is a case where it could not be used at all, and 
are these cases to be let alone because we cannot fix the pedicle 
in the abdominal wound? 
In a conversation with the distinguished Dr. Bantock, of 
London, I expressed the hope that in the near future we should 
be able to remove fibroid tumors with the same low rate of 
mortality as we now remove ovarian tumors. He expressed a 
doubt as to whether that could ever be accomplished, adding 
that the anatomical conditions were essentially different. This 
remark discouraged me in one direction, but encouraged me to 
make as thorough study as possible of all the anatomical con- 
ditions pertaining to the uterus and the development from the 
tissue of that organ of fibroid tumors. In looking up some 
seven authoritative text-books on anatomy, I find they state that 
the coiling or spiral arteries (which are supplied with blood 
from the uterine and ovarian arteries) penetrate the uterus. I JOSEPH EASTMAN. 
5 
am well convinced that this statement must have come from the 
theorist of the closet or the book-worm of the library, and has 
had much to do in retarding the progress and in perfecting the 
technique of hysterectomy. 
Sauter, of Constance, Germany, three-quarters of a century 
ago, removed the uterus per vaginam without clamp or ligature, 
practically contradicting the teachings of our modern text-books. 
(See article by Dr. Guido Bell.) Further, the enucleation of 
the cervix per vaginam was made by Langenbeck in 1813, by 
Recamier in 1829 and by Malgaigne at a later date. (See arti- 
cle by Dr. Robt. Reyburn.) Here is a nodular mass fed and 
nourished by a capsule-a capsule containing the venous and 
arterial capillaries. It is well known to every gynecic surgeon 
that these nodules can be peeled out of the capsule without 
ligating a single artery. What I have stated regarding the 
nourishment of this nodule by its network of capillaries, and not 
bv the penetration of the arteries, holds true with reference to a 
uterus disorganized by fibroid tumor or tumors, no matter how 
large or how small ; not only the fibroid uterus but the normal 
uterus ; not only the uterus but its entire cervix down to the 
external os. 
I here present a specimen (see Figure 1)-a photograph of 
which vou may see in the American Journal of Obstetrics and 
Diseases of Women for the present month, and to my mind it 
marks a new era in the removal of fibroid tumors by hysterec- 
tomy for the reason that the uterine arteries were not ligated 
at all. I went down between the uterine arteries and the 
uterus. The uterine arteries were absolutely left in the pelvis 
of the woman, not a single ligature being used except those 
which tied off the ovarian arteries and a small portion of the 
upper border of the broad ligaments.* 
Then in addition to solving the problem as to what to do 
with the pedicle by deciding not to have any, we now solve the 
problem as to what to do with the broad ligaments, and espec- 
*A ligature to secure the uterine arteries will often secure a certain amount of 
muscular and connective tissue and is one of the possible sources of infection of 
the wound, hence the importance of having as few ligatures constricting tissue in 
this work as possible. 6 
STATE MEDICAL SOCIETY. 
ially their contained uterine arteries, by simply leaving them in 
the pelvis of the patient. In this case I simply controlled the 
circulation in the ovarian artery by ligating the upper portion 
of the broad ligaments with a strong ligature, then cutting 
FIG. I. 
FIG. 2. 
above the ligature began with this serrated gouge (see Figure 2) 
to peel down the broad ligaments, keeping the gouge close to 
the tumor, being especially careful in inter-spaces between the 
nodules not to puncture or tear the uterine artery or any of 
its branches. From time to time nicking the edges of the 
capsule with these button-pointed scissors, with the serrated 
■cutting edge, I pushed it forward under the capsule, anterior 7 
JOSEPH EASTMAN. 
and posterior, so as to make anterior and posterior flaps. Then 
pushing with the serrated gouge I carefully worked around 
the tumor until I had reached the uterine cervix, and then 
proceeded with still greater caution not to cut the cervix nor 
its capsule, but to push it down as I now slip my cuff toward 
my elbow with the fingers of my right hand. 
This enucleation of the lower portion of the uterus, enucleat- 
ing its cervix, reminds me of Prof. Sayre's admonition when 
removing the head of the femur for hip-joint disease. He says, 
" I take this oyster knife and work my way past the trochanters, 
major and minor, then make sure to get beneath the periosteum 
close to the bone." " Then," he used to say, " d-n the 
anatomy, stick close to the bone," and proceeded in peeling off 
the periosteum until he had the entire head of the femor out of 
the acetabulum. 
As I reached this lower part of the cervix, my hysterectomy 
staff was passed up the vagina by my son, Dr. Thomas B. 
Eastman. I then removed the entire cervix, cutting a little 
opening on to the staff, slipping a strip of iodoform gauze in 
the fenestra of the staff. When the staff was withdrawn this 
was brought down in the vagina, the upper portion of the 
gauze being packed into the pocket from which the cervix had 
been enucleated. The flaps which I had dissected off from the 
tumor and cervix were brought together by buried suture over 
the ligatures which had included the ovarian arteries, so that 
their raw ends also came into the wound. Several rows of 
buried suture were used, so that all raw edges made by peeling 
out the cervix were deeply buried so as to prevent leaking into 
the peritoneal cavity, the gauze being dragged down into the 
vagina a little each day, facilitating perfect drainage in that 
direction. 
This operation is a realization of the ideal. Heretofore all 
of us had simply been idealizing the real. In my lecture 
delivered to the Post-graduate School of Chicago, in July, 1893, 
I closed with a series of conclusions. From them I quote the 
third, to-wit: "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 8 
STATE MEDICAL SOCIETY. 
wound and give satisfactory results." To this conclusion stated 
at that time I have this to add: Where such anatomical condi- 
tion exists, enucleation of the cervix can be done in less time 
than the manufacturing of the pedicle, the adjustment of the 
serre-noeud, or elastic ligature. Furthermore, abdominal fixa- 
tion of the pedicle cannot be accomplished in all cases, nor can 
we know until the abdomen is opened that a given tumor is so 
imbedded in the pelvis that a pedicle could not be formed. 
Therefore, while I respect the method for the good it has done, 
I shall no longer sanction it because it is not applicable to all 
cases. 
The enucleation of tumor, nodules, uterus, and cervix is a 
method / challenge the universe to add to or detract from. It 
leaves nothing to be desired by way of simple surgical technique 
or satisfactory results. In the last few years, I have a number 
of times left the greater portion of the uterine arteries to 
remain in the pelvis of the patient, but from the results I had I 
was thinking that the possibility of infection through the rich 
chain of lymphatics at the side of the uterus was greater in 
such cases than where broad ligaments were thoroughly con- 
stricted by ligature all the way down to the opening in the 
vagina. This led me to express, in the Chicago lecture hereto- 
fore referred to, my preference for cutting around the cervix 
rather than enucleating it. But carefully reflecting over the 
statement of Dr. Bantock, that the anatomical conditions were 
essentially different in fibroid tumors from what they are in 
ovarian cysts, I have become thoroughly convinced that we often 
find fault with the technique which we have used in treating the 
pedicle when the cause of death ought to be explained in some 
other way. For example, when the parietes of the abdomen 
are rendered thin by the pressure of an ovarian cyst, the blood 
supply is reduced so that all the intra-abdominal viscera are 
more or less aneemic. This condition is in marked contrast with 
the hypernutrition often present in and about the pelvis which 
contains a fibroid tumor. I am quite sure that deaths occur in 
consequence of our almost losing our heads in the determina- 
tion to make the pedicle and all pertaining thereunto as perfect 
as possible, and neglecting to make as perfect approximation of JOSEPH EASTMAN. 
9 
the abdominal incision, always large as tumor, including its peri- 
toneum, as we should do. I have many times cut through two 
inches of fat to reach a fibroid tumor, and unless such a wound 
be thoroughly closed by three rows of sutures, the internal one 
being fine silk with stitches not more than the fourth of an inch 
apart, and then making absolute sero-serous approximation, 
there is danger of infecting the peritoneal cavity by the wound 
leaking into the abdomen. Too often we take extreme precau- 
tions to nicely adjust the outer integument when it would be 
better if any leakage from the wound is to occur that it shall 
pour outwardly rather than inwardly. Again, the more vascu- 
lar condition of the peritoneal cavity and its contained viscera 
in cases of fibroid tumors as compared with ovarian cysts, warns 
us of the greater intolerance of rough manipulations, making 
it necessary to protect the intestines and viscera as much as 
possible during operation by hot sterilized towels or sponges, by 
temporarily bringing the wound together over the intestines 
with a temporary stitch or vulsella; and above all and over all 
the most thorough irrigation of the peritoneal cavity with 
water at not less than no0, not only after the work has been 
completed, but at intervals during the work, so as to undo the 
harm we do to the vaso-motor nerves distributed to the pelvic 
and abdominal viscera. Half a dozen pitchers full of water 
are none too many, and if we have produced material shock as 
evidenced by the pulse, a few pitchers of water poured 
through the drainage tube and allowed to pour out again has at 
times, as I .believe {permit me to say, I absolutely know\ saved 
lives that otherwise would have been lost. The operator of 
to-day who seeks to do away with the "wash out" and the 
drainage tube on theoretical grounds is rolling the wheels of 
progress backwards. The skillful management of a patient 
during shock is of very great importance indeed. The use of 
opium to put the disturbed tissues at rest, as advocated by Dr. 
Eugene Boise, of your Society, in his recent able article on the 
treatment of surgical shock, has the genuine ring of surgical 
wisdom. The use of strychnia to keep up the tone of the 
nerves distributed to the intestinal tract and thereby counteract 
the tendency to gaseous distension of the bowels, is one of the 10 
STATE MEDICAL SOCIETY. 
precious comforts to the anxious surgeon when his patient is 
low in shock. 
CONCLUSIONS. 
The following conclusions, I think, are justifiable: ist, Where 
the morphology of tumor is such that abdominal fixation can be 
used, the enucleation of the cervix is easy and successful, requir- 
ing very little time, as no ligatures of any consequence need to 
be used. 2nd. In deciding between two methods equally suc- 
cessful and speedy, the one applicable to all cases and the other 
not, our preference should be for the method applicable to all 
cases. 3d. In this method of enucleation, great care should be 
taken to have the opening between the wound and vagina large 
enough to admit of easy removal of the gauze which has been 
packed into the wound for drainage. 4th. The closure of the 
flaps peeled off from the tumor should be very carefully made, 
so that perfect sero-serous approximation of the margins of the 
flaps may be secured, to the end that there can be no leaking 
from the wound into the peritoneal cavity. 
When Ephraim McDowell made his first ovariotomy, the 
citizens surrounded his house, threatening his life, because he 
was about to " butcher a woman." The sheriff of the county 
interfered. At first they refused to listen to his pleadings for 
the doctor's life. Finally he struck a compromise, the mob 
agreeing to let the doctor alone if the woman recovered, the 
sheriff agreeing not to interfere with the mob if the woman 
died. This was a crucial test of the doctor's heroism. Other 
heroic surgeons for years removed ovarian tumors, allowing 
women to pass on to their graves if the diagnosis convinced 
them that it was a fibroid tumor instead of an ovarian cyst. 
Even the great and noble Dr. Thomas Keith, after battling with 
fibroid tumors, .with as good a per cent, of recoveries as any one 
at that date, finally abandoned fibromectomy, resorting to the 
use of electricity, and only wished that he had back from their 
graves the patients that had died from his operations for fibroids. 
Thank God, there were others to take up the work when he got 
discouraged. The old adage that the qualifications of a surgeon 
were " the head of an Apollo, the eye of an eagle, the heart JOSEPH EASTMAN. 
11 
of a lion, and the hand of a woman," is eminently true, espe- 
cially to him who would seek to be successful in removing fib- 
roid tumors. The head to plan and to meet the surprises which 
spring on us during such work ; an eye to see quickly the exact 
constriction of every ligature and adjustment of every suture ; 
the lion heart to forge forward in this aggressive work when 
our per cent of recoveries might be better if we would let fib- 
roid tumors alone ; the nimble wit in the end of the fingers, 
backed by an indomitable will to skillfully and speedily perfect 
the adjustment of the last suture with the same precision as the 
first, make a combination of qualifications, suggesting that 
the surgical type of a man is not to be found thirteen times in a 
dozen. 
There is no operation that I know of which so thoroughly 
demands that the trinity of surgery be complied with, thorough 
preparation of the patient, thorough operating and skillful after- 
treatment. As American surgeons, we have a right to be proud 
that no other nation leads us in the originality of methods or 
successful results in removing fibroid tumors. Almost every 
state of our Union has operators, who would venture to give a 
woman with a fibroid tumor the chances of life which surgery 
offers for her relief. 
With a more thorough and perfect understanding of the 
essential anatomical conditions which make an abdomen con- 
taining a fibroid tumor different from one containing an ovarian 
cyst, with the realization of the ideal method applicable alike to 
all fibroid tumors regardless of their morphology, as successful 
in the hands of the many as the few, we can say with all sin- 
cerity that fibroid tumors can be removed with the same low 
rate of mortality which has placed ovariotomy among the bril- 
liant triumphs of the century. Then shall the torch, lighted by 
McDowell in the midnight darkness, shine forth with resplen- 
dent glory in this brilliant noonday of abdominal surgery. The 
century, which in a few years will have rolled on to the eternal 
past, has placed in the magnificent temple of medicine many 
columns of surpassing beauty and grandeur, while its surgical 
pillars have risen high toward heaven, where, as gilded towers, 12 
STATE MEDICAL SOCIETY. 
they fain would vie with the God-given sunshine in dispelling 
the chill and gloom of human agony. 
Chirurgia's tower, thy light's resplendent blaze 
Dries woman's tears, and lengthens out her days; 
McDowell and Sims, of our Columbia's clime, 
Began the work pushed onward nigh sublime. 
To woman, then, these blessings shall be given, 
Queen of the home, and home the type of Heaven. 
Abdominal surgery is proud of her past because it is pro- 
phetic of her future. Even now in the vital present it shall 
stand forth unchallenged as the crowning glory of all science 
and of all art. 
(At the close of his paper, Dr. Eastman exhibited a siphon, 
used with a large drainage tube with many openings, and which 
he calls ''Jacob's well." He uses it a good deal in his abdom- 
inal work. It secures all the advantages of running water 
through Douglas's cul-de-sac).