•Reprinted from Annals of Gynaecology and* 
Podiatry, May, 1891. - 
Vaginal Hysterectomy for Cancer, with Reports of Twenty- 
one Cases (with Nineteen Recoveries). 
BY ERNEST W. CUSHING, M.D. 
With Plates I and II. [Annals of Gynaecology and Podiatry, May, 1891.] 
PLATE I. 
Fig. i. 
Malignant Adenoma of Uterus, Vaginal Hysterectomy. 
A Fundus: below this the cavity of uterus is laid open. 
B Part of thick friable uterine wall, torn away from part at C. 
D Cervix, diseased and sundered from body during operation. 
E Ovary. 
[See Page 4.] [Annals of Gynaecology and Podiatry, May, 1891.] 
PLATE 11. 
Fig. i ( x 50.) 
Fig. 2. 
( X 150.) 
Fig. 3. 
From curettings of case shown in Plate I, performed three months before vaginal hysterectomy ; four ounces 
of tissue were removed by the curette. 
Fig. 1. New glands with little interglandular tissue. 
Fig. 2. The same with higher power, showing columnar epithelium. 
Fig. 3. The same, showing budding of glands, in solid sprouts, which afterward became hollow, 
[See Page 4.] 
Adenoma of Uterine Mucous Membrane. Vaginal Hysterectomy for Cancer, with Reports of Twenty- 
one Cases (with Nineteen Recoveries).1 
BY ERNEST W. CUSHING, M.D. 
I desire, this evening, to call 
your attention, not so much to the 
technique of vaginal hysterectomy, as 
to certain questions concerning the 
indications for this operation, the 
choice between total and partial extir- 
pation of the uterus, the limitations 
within which total extirpation can 
and should be performed, and the re- 
sults obtained. I will, therefore, con- 
sider these subjects in preference to 
those of the technique and various 
methods of the operation. 
At the very outset we are met by 
the question of the diagnosis of cancer 
of the uterus, and of the differentiation 
of the various forms of the disease in 
this organ. Although in many cases 
it is very easy to make a diagnosis, 
simply by gross appearances, which 
are sufficiently familiar to all physi- 
cians of experience, yet unfortunately, 
when the affection has reached a 
where recognition is easy, it is often 
impossible to perform total extirpa- 
tion, at least with any prospect of suc- 
cess, and our whole endeavor should 
be, therefore, to seek a definite diag- 
nosis as early as possible. In the in- 
cipient stages of malignant disease 
total extirpation is easy, and not very 
dangerous, and it gives excellent pros- 
pects of permanent recovery, while if 
delayed too long, not only does the 
operation become far more formidable 
and difficult of accomplishment, but 
the recurrences are so frequent as to 
With Plates I and II. 
discredit all such operations. It may 
be said, and by many it is claimed, 
that when cancer is discovered early, 
and is limited to the cervix, a partial 
operation is all that is necessary, and 
great importance has been attached 
to the results of Schroeder and Hof- 
meier. The statistics published by 
the latter show that a far larger pro- 
portion of the cases operated on by 
Schroeder and himself by high ampu- 
tation of the cancerous cervix remained 
freer from relapse than was the case 
after those operations where the whole 
uterus was removed; from this fact 
many writers have jumped at the con- 
clusion that a partial amputation was 
not only an easier and safer operation 
than total extirpation, but that it gives 
the greater security against relapse. 
To understand this question properly, 
however, it is necessary to remember 
that the cases which Schroeder and 
Hofmeier treated by high amputation 
of the cervix were those of cancroid 
(epithelioma), in which the disease 
was entirely limited to the vaginal 
portion of the cervix, and were, there- 
fore, cases where the cancer was de- 
tected and removed at an early stage, 
and where it was of a nature tending 
to remain localized. On the other 
hand, the cases which Schroeder and 
Hofmeier operated on by total extir- 
pation were those in which the cervix 
itself was involved, or where there was 
malignant disease of the body of the 
uterus; therefore it is very evident 
that in their hands the chances of re. 
1 Read, by invitation, before the Obstetrical Society 
of Boston, March 14, 1891. 2 
ERNEST W. CUSHING. 
lapse after total extirpation were much 
worse than after the high amputation 
of the cervix. In other words, they 
selected for the lighter operation cases 
of extremely limited and incipient dis- 
ease, and in such there was, neverthe- 
less, a very large percentage of recur- 
rences, i. e., over fifty per cent. It 
seems hardly doubtful that there would 
'be fewer recurrences if the whole 
uterus were removed, even in cases 
where the disease is merely cancroid 
of the vaginal portion, and the con- 
sensus of opinion among continental 
observers is now decidedly in favor of 
removing the whole organ whenever 
the diagnosis of malignant disease is 
clear. This view of the case I accept 
without hesitation. It should not be 
forgotten that the high amputation of 
the cervix is a difficult and somewhat 
dangerous operation, requiring a great 
deal of technical skill. In any case 
in which this operation can be per- 
formed, the total removal of the uterus 
can be accomplished with little addi- 
tional difficulty or danger, and affords 
greater security against haemorrhage, 
as well as greater immunity from re- 
lapse. The customary classification 
of malignant disease of the cervix, as 
established by Schroeder, is (i) can 
croid of the vaginal portion (corre- 
sponding to what is frequently known 
as epithelioma); (2) carcinoma of the 
mucous membrane of the cervix; (3) 
carcinomatous nodule of the cervix. 
The specimens here presented and 
the preparations exhibited under the 
microscope show these various forms, 
and it is to be remembered that it is 
only in the first and rarest of these 
three varieties that there is any claim 
of the efficiency of partial removal of 
the uterus. In both the other vari- 
eties, common by consent, total extir- 
pation should be performed immedi- 
ately on discovery of the disease, if 
haply it is not already too late to 
accomplish it. 
It must not be forgotten that where 
carcinomatous disease of the cervix is 
present, even when the affection is 
limited to the vaginal portion, it is al- 
ways possible that the malady may 
also extend to the fundus, and for this 
reason alone, if for no other, total ex- 
tirpation is indicated in all cases. I 
am aware that Hofmeier contends 
that there are but very few authenti- 
cated cases of simultaneous affection 
of the fundus and vaginal portion, ex- 
cept where the process is primary in 
the fundus, and secondary in the 
vaginal portion. Although, however, 
this view may be maintained academi- 
cally, and as a matter of rigid micro- 
scopical diagnosis, rejecting all cases 
where the description of the micro- 
scopical preparations is not entirely 
satisfactory, yet practically it is cer- 
tainly possible, in a given case of ma- 
lignant disease of the cervix, that por- 
tions of the tissue above the internal 
os may be affected with similar dis- 
ease, either secondarily or primarily, 
whether by continuous spread of the 
degeneration or by the formation of 
an independent focus; such a possi- 
bility is sufficient to make total extir- 
pation preferable to high amputation, 
for the slightly increased risk of the 
operation is much less important than 
the terrible danger of relapse, or 
rather of the continued existence and 
progress of an undiscovered focus of 
disease. What surgeon would be con- 
tent to excise a carcinomatous nipple 
with the adjacent parts only? Do not 
conscientious operators try to remove 
not only all portions of the mammary 
gland, but even the contents of the VAGINAL HYSTERECTOMY FOR CANCER. 
3 
axilla, because by doing so, although 
the primary mortality of the operation 
for cancer of the breast is largely in- 
creased, the chances of relapse are 
diminished in a much greater pro- 
portion ? 
In regard to the diagnosis of cancer 
of the cervix I shall say little, as the 
subject is elaborately discussed in all 
the text-books. In many cases the 
diagnosis is perfectly simple, but in 
others it can only be made by the 
microscope. I will only emphasize 
here the manifest duty of the general 
practitioner, to make a careful physical 
examination of women who complain 
of irregular haemorrhages ; especially 
when they are over 30 years of age 
is the existence of cancer to be con- 
sidered, and many valuable lives would 
be saved if physicians would examine 
their patients carefully instead of pre- 
scribing for menorrhagia and metror- 
rhagia, as if these were diseases in 
themselves, and not mere symptoms, 
imperatively demanding an accurate 
diagnosis. When examination, how- 
ever, is inconclusive and merely shows 
a raw and angry condition of some 
part of the os externum, usually the 
site of a laceration from some previ- 
ous labor, particularly if the condition 
is intractable under treatment, and if 
the place bleeds easily when touched, 
a sufficient piece should be removed 
co permit of a microscopic examina- 
tion by an expert. For this purpose 
a wedge-shaped fragment should be 
excised with scissors, going rather 
deeply into the tissues of the cervix. 
If bleeding is severe, and is not con- 
trolled by styptic cotton, a stitch may 
be necessary to stop it. When the 
tissues are friable, so that a consider- 
able portion can be removed with a 
sharp spoon or with the finger-nail, 
the affection is almost certainly ma- 
lignant. 
In regard to malignant disease of 
the body of the uterus, I suppose that 
there is no question but what total 
extirpation is imperatively indicated, 
whenever it can be accomplished, and 
as soon as a diagnosis can be made. 
Here again the microscope is of the 
greatest advantage, for the haemor- 
rhages are usually such as to call for 
curetting, and diagnosis of malignancy 
can be made without difficulty from 
the masses removed by the curette, 
not only by the aid of the microscope, 
but often by their gross appearance, 
the fragments being whitish, thick and 
friable, and quite unlike mucous mem- 
brane. Here again the greatest ser- 
vice can be done by our profession, 
by teaching the women who are under 
their care that irregular haemorrhages 
at the time of the menopause, especi- 
ally when protracted and severe, are 
not to be simply considered as almost 
necessary phenomena of the change 
of life. 
The beliefs of the laity in medical 
matters are not mere superstition, but 
usually reflect pretty accurately those 
theories which were current in the 
medical profession from twenty to 
forty years previously. The women 
of the present generation are vastly 
better informed about their generative 
organs and functions than were their 
mothers or grandmothers. It is very 
probable that they know a great deal 
more about these subjects than is good 
for them; but, at any rate, one thing 
should be assiduously taught and in- 
sisted on by the profession, and that 
is that irregular and profuse haemor- 
rhages, especially after the meno- 
pause, are of very serious import. In 
this connection I wish to call attcn- 4 
ERNEST W. CUSHING. 
tion to a condition which is not very 
uncommon, and which is not usually 
well understood, viz., to a transition 
state of adenomatous thickening of 
the mucous membrane of the body of 
the uterus in elderly women, which 
finally degenerates into carcinoma. 
(Plate I.) In these cases, after the 
menopause has been established per- 
haps for several years, irregular 
haemorrhages begin, which are usually 
relieved by curetting; this operation 
has to be repeated many times, at 
intervals of a few months, very con- 
siderable masses of tissue, resembling 
mucous membrane, being removed, 
which, under the microscope, are found 
to be composed almost entirely of 
glands with very little intervening con- 
nective tissue. (Plate II, Figs. 1,2,3.) 
All these cases eventually terminate 
in carcinoma, and therefore total ex- 
tirpation should not be delayed, al- 
though I have known the radical oper- 
ation to be discountenanced by a 
pathological expert who misinter- 
preted the microscopical appearances 
as implying a benign hyperplasia of 
the uterine mucous membrane. 
I have now performed the operation 
for vaginal hysterectomy twenty-one 
times, in every case for cancer or 
malignant adenoma of the uterus; the 
youngest patient was 26, the oldest 
66 years of age. All the patients re- 
covered from the immediate effects of 
the operation, except one, who was 
operated upon in another State, and 
was not seen by me after the operation, 
and who died at the end of a week, 
with symptoms of peritonitis, with very 
obstinate vomiting. Another patient, 
one of the early cases, where the dis- 
ease had invaded the left broad liga- 
ment so that the clamps had to be 
applied in unhealthy tissue, did very 
well for ten days, so that she was con- 
sidered out of all danger. She felt so 
well that, without permission, she sat 
up in bed to take her supper. The 
same night the patient in the next bed 
heard her make a strange sound, and 
saw her make a convulsive movement; 
the night nurse, who quickly went to 
her bedside, found her dead. No 
autopsy was made, but it was thought 
probable that death was attributable 
to embolus from the detachment of a 
clot in the stump. All the other cases 
recovered, having a remarkably easy 
convalescence. One case was oper- 
ated on ten months ago in Providence, 
Rhode Island, where the disease 
had advanced in the anterior and 
posterior cul de sac so far that the 
removal of what remained of the uter- 
us was performed as the best means 
of taking away as much of the disease 
as possible, and of giving security 
against haemorrhage, although it was 
certain that all of the carcinomatous 
tissue was not removed. This patient, 
however, was able to get up, and did 
well for several months after the oper- 
ation, and is still living. Subtracting 
from the whole number of twenty-one 
cases the one which died from the 
operation, and three cases, including 
the two above mentioned, where the 
whole of the diseased tissue could not 
be removed, and one of whom died, 
there remained seventeen cases where, 
with greater or less difficulty, the whole 
uterus was removed and the clamps 
applied to apparently healthy tissue. 
Six of these operations have been per- 
formed within the last six months and 
are, therefore, unavailable as far as re- 
gards the question of recurrence. At 
any rate, the patients are doing well 
so far. Of the eleven other cases 
which recovered and which have been VAGINAL HYSTERECTOMY FOR CANCER. 
5 
operated on for a year or more, three 
are dead, and one will soon die from 
recurrence of the cancer. The other 
seven are in excellent health, as well 
as the six recent cases above referred 
to. With a single exception, already 
mentioned,'the convalescence was ex- 
tremely easy and uneventful. There 
was no elevation of temperature or 
any sign of peritonitis. The scars 
left in the vagina were smooth and 
painless. One patient has since mar- 
ried, and another proposes to commit 
matrimony at an early date. In two 
cases the bladder was injured at the 
time of the operation, and in three 
others the patients began to "leak" a 
few days after the operation. In all 
these cases, however, I had no diffi- 
culty in repairing the fistula at a later 
date. In two it closed of itself. In 
one the opening into the bladder was 
complicated by a section of the ureter, 
which emptied into the vagina; I suc- 
ceeded, however, in passing a sound 
through the urethra and bladder out 
into the vagina and then into the con- 
tiguous opening of the ureter. Then 
by a plastic operation I covered the 
sound in with mucous membrane, so 
that the ureter was turned into the 
bladder and gave no further trouble. 
The original operation in this case 
had been a very difficult one, and the 
cervix had already been curetted and 
cauterized in another hospital. 
In regard to the technique of the 
operation, I will not occupy much of 
your time. I always use clamps in- 
stead of ligatures, not only because 
thereby the operation is shortened, 
and haemorrhage more safely con- 
trolled, but because the weight of the 
handles of the clamps insures thor- 
ough drainage, and the tissues seized 
by the clamps can be crushed, and the 
lymphatics obliterated, before the scis- 
sors are used, thus diminishing the 
chances of cancerous infection of the 
lymphatics of the stumps and broad 
ligaments, and permitting the sever- 
ance of the latter further from the 
uterus than would be possible by the 
use of the ligature alone. 
I have brought here for your inspec- 
tion the uteri removed by total extir- 
pation in the case above referred to; 
an inspection of these will give, better 
than any description, an idea of the 
condition of the cancerous uterus ; of 
the tendency of the affection to ex- 
tend above the internal os; of the 
varying distance, both in front and 
behind, at which the peritoneum is 
reflected from the body or neck of the 
uterus ; of the adhesions which may 
tie down the fundus or hold the tubes 
and ovaries fixed, thereby greatly 
complicating the operation and render- 
ing it extremely difficult. Of all the 
twenty-one cases, I can remember only 
five where the organ could be easily 
drawn down and the clamps applied 
with the facility described in some 
accounts of the operation; in two 
cases there were present small ova- 
rian tumors, which were removed 
through the vaginal opening; one was 
a dermoid, one a multilocular cyst. 
Besides the cases reported above, I 
have twice opened the abdomen from 
above, and once from the posterior 
cul de sac, to decide as to the feasi- 
bility of total extirpation, but have 
found the disease spreading to such 
an extent as to contraindicate any 
attempt to perform such an operation. 
All of these three patients recovered 
from the exploratory incision without 
any difficulty. 
The preparations exhibited under 
the microscopes, and others which I 6 
ERNEST W. CUSHING. 
have brought to-night, show very well 
the appearances of carcinoma of the 
uterus. Some of them I made myself, 
and some were kindly made from my 
specimens by Drs. Haddock, of Bev- 
erly, and Cottrell, of Boston. I call 
particular attention to the preparations 
showing the carcinomatous degenera- 
tion of the uterine gland,1 and to those 
displaying the peculiar structure of 
malignant adenoma.2 In regard to the 
limitations of this operation, they are 
well defined, and the results as to re- 
currence have been much better since 
the operation has been refused in un- 
suitable cases. The main point is to 
be sure that the disease has not in- 
vaded the broad ligament to such an 
extent that cancerous tissue would 
have to be left within or beyond the 
grasp of the clamps. This can usu- 
ally best be determined by examina- 
tion through the rectum, especially 
when the uterus is drawn down with 
the bullet forceps or tenaculum. Of 
course, cases where the disease has 
spread over the vagina, or has involved 
the tissues about the rectum or blad- 
der, or where there are deposits in the 
pelvis, or metastases in other organs, 
are unsuitable for operation. Secondly, 
the uterus must be reasonably mov- 
able, so that it can be drawn down, as 
the presence of old adhesions, even 
when not of a malignant nature, is a 
very serious complication, which can 
only be overcome by carefully sepa- 
rating the adhesions with the fingers 
in the space of Douglas, as was done 
in some of the above cases, or by 
making an abdominal incision for this 
purpose, which, of course, greatly in- 
creases the severity of the operation. 
Thirdly, the vagina and the space 
between the pelvic bones must be wide 
enough in comparison with the size of 
the tumor to allow the removal of the 
latter. This condition applies partic- 
ularly to women who have never had 
children, and in whom malignant 
disease generally attacks the body of 
the uterus, whereas in women who 
have borne children the cervix is usu- 
ally affected. 
Operation may also be contraindi- 
cated by the presence of serious dis- 
ease of other organs, or by great 
weakness from cachexia, or from loss 
of blood, although in the latter condi- 
tion a preliminary operation of scrap- 
ing and burning out the diseased mass, 
followed by rest in bed, attention to 
cleanliness, liberal food and tonics, 
will sometimes bring the patient into 
a condition which permits the per- 
formance of radical operation. 
• 1 See micro-photographs in Martin, Diseases of 
Women, 2d Am. Ed. Plates XVII-XXVIIL 
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