The Early History of Vaginal Hysterectomy.

Delivered before the Chicago Medical Society, March 18,1895.

N. SENN, M.D., Ph.D., LL.D.PROFESSOR OF PRACTICE OP SURGERY AND CLINICAL SURGERY, RUSH

MEDICAL COLLEGE ; PROFESSOR OF SURGERY, CHICAGO POLICLINIC;ATTENDING SURGEON PRESBYTERIAN HOSPITAL; SURGEON-

IN-CHIEF ST. JOSEPH’S HOSPITAL.CHICAGO.

RERRIN'TED FROMTHE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION

SEPTEMBER 21, 1895.

CHICAGO;American Medical Association Press.

1895.

The Early History of Vaginal Hysterectomy,

Delivered before the Chicago Medical Society, March 18,1895.

N. SENN, M.D., Ph.D., LL.D.PROFESSOR OF PRACTICE OP SURGERY AND CLINICAL SURGERY, RUSH

MEDICAL COLLEGE ; PROFESSOR OP SURGERY, CHICAGO POLICLINIC ;

ATTENDING SURGEON PRESBYTERIAN HOSPITAL; SURGEON-IN-CHIEF ST. JOSEPH’S HOSPITAL.

CHICAGO.

REPRINTED FROMTHE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION

SEPTEMBER 21, 1896.

CHICAGO:American Medical Association Press,

1895.

THE EARLY HISTORY OF VAGINAL HYS-TERECTOMY.

Every great operation in surgery has a period ofevolution of varying duration. Each marked ad-vance in medicine and surgery is preceded by at-tempts which led to the elucidation of old ideas orthe conception of new ones. All great discoveriesare overshadowed by the labors of a host of earnestand progressive workers which ultimately crown theefforts of a favored few. Nearly all of the improve-ments in medicine and surgery which have char-acterized the present progressive age are only arepetition of the work of our professional ancestors.Many a so-called modern operation is only a recentand not always an improved edition of the operativetechnique as devised and described by one of the oldmasters. These remarks apply with special force tovaginal hysterectomy. The operation of removingthe carcinomatous uterus through the vagina, sorecently developed to its present state of perfection,was planned and performed by men who have longsince departed, but whose names will always be inti-mately associated with the interesting history andgradual development of this operation.

There can be no doubt that the first ideas whichled to the plan of removing a diseased uterus throughthe vagina were based upon the results which followedthe unintentional removal of the uterus in cases ofmistaken diagnosis. All of the early operations weredone for prolapse or inversion of the uterus. Theidea of removing the uterus through the vagina orig-inated with Soranus, who was a distinguished obstet-rician in Rome during the reign of Emperor Had-rian. The first authenticated description of removal

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of the uterus through the vagina was given by Beren-garius, of Bologna, in 1507. Like all of the earlycases, we are ignorant as to the exact pathologic con-ditions for which this operation was made, but therecan be no doubt that part of the uterus was removed.J. Schenck a Grafenberg (1617) relates a number ofcases in which the uterus was removed through thevagina, in whole or in part, by ignorant persons whohad not the faintest ideas as to the nature of thedifficulty or of the extent and gravity of the opera-tion. In 1792 Laumonier removed an inverted uterusbelow a ligature. The patient died six weeks afteroperation. The post mortem showed cicatricial ob-literation of the vagina, absence of the uterus; theovaries and tubes were found on the side of the rec-tum. Baudelocque examined the specimen later andfound that the inversion was caused by an intra-uterine growth and explained that the operation waslimited to the removal of the tumor, and that theuterus was removed later by the application of a lig-ature which opened the peritoneal cavity and causedthe fatal suppurative peritonitis. Beyerle, on theother hand, asserted that the entire uterus was re-moved at the first operation. Other cases of vaginalremoval of the inverted uterus, with or without thepresence of a uterine tumor, have been reported byBardol, Marc-Antoine, Petit de Lyon and Widmann.Cases of unintentional, partial or complete vaginalhysterectomy are also related by Sclevogt, J. Rams-botham, Figuet and Blasius. Instances of partial orcomplete removal of the uterus in which the organwas rudely removed by midwives have been reportedby Hildanus (1646), Wrisberg (1785) and Bernhard(1824). In the case reported by Bernhard the in-verted uterus was removed by the midwife with arazor, the profuse hemorrhage was controlled by theintroduction of fragments of ice into the vagina, andthe woman recovered.

Cases of intentional removal of the uterus by sur-geons have been recorded by Zwinger, Vieussen,

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Baxter, Faivre, Alexander Hunter, Joseph Clarkeand Johnson. In Zwinger’s case the amputation wasmade soon after delivery after preliminary ligation.Death two days after operation. The post-mortemshowed that the middleportion of the uterus had beenremoved. In Baxter’s case the uterus was amputatedin the same manner five weeks after delivery. Re-covery six weeks after operation.' Faivre applied aligature to therecently inverted uterus wT hich sloughedand was detached on the twenty-seventh day afterligation, followed by recovery of the patient.

Johnson cut off the uterus below the ligature andhis patient made a good recovery. In a second caseof recent inversion of the uterus, the same surgeon ap-plied a ligature to control the profuse hemorrhage.The hemorrhage ceased and the ligature was removedtwo days later. The hemorrhage returned, when theuterus was again ligated, and fourteen days later thefundus and tubes were detached in the form of aslough, after wr hich the patient made a satisfactoryrecovery.

Windsor (1819) operated on a case of chronic in-version by tying a silk ligature around the uterus.He tightened the ligature more firmly every eveningand on the twelfth day after the ligature had cut itsway nearly through the tissues, he cut off the uterusbelow the ligaturewithout incurring any hemorrhage.The specimen removed was three inches in lengthand consisted of the uterus, round ligaments and aportion of the tubes and ovaries. After a protractedillness the patient ultimately made a favorable re-covery. In Weber’s case the inversion was caused byan intra-uterine tumor, hastened by a midwife, whomade an attempt to remove the tumor by traction.Weber ligated the fundus of the uterus, tightened theligature daily, and cut off a piece below it four andone-quarter inches in diameter, and an inch and ahalf in length. The specimen removed containedportions of the tubes. Eight days after the applica-tion of the ligature the ligated mass sloughed off.

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The woman recovered without any untoward symp-toms and remained in good health a year after theoperation.

Rheineck operated on a similar case. The patientwas a multipara, 41 years of age. The entire uteruswas removed by the use of a ligature. A careful ex-amination after recovery of the patient showed notrace of the uterus. In many of the cases operatedupon before 1800, the diagnosis was uncertain, but inmost instances the operation was performed forsimple or complicated inversion of the uterus.

Vaginal hysterectomy for malignant disease of theuterus dates back to the year 1812, when Paletta ap-pears to have removed the entire organ. The extentof the disease is unknown, but the tumor occupiedthe lower segment of the uterus. Paletta did notknow that he extirpated the entire uterus until heexamined the specimen after the completion of theoperation. The patient suffered for nine monthsfrom pain in the back and hips and a copious sero-sanguinolent vaginal discharge. The cervical por-tion of the uterus was the seat of an ulceratingtumor. The operation was performed April 13,1812.By the use of obstetric forceps and the hand, theuterus was brought down to the vaginal outlet. Theupper part of the vagina was incised with a pair ofcurved scissors. After separating the lower segmentof the uterus a hard body could be felt at the base ofthe tumor. This hard body proved to be the fundusof the uterus which remained in connection with thetumor. The patient died at the end of the third day.Paletta didnot intend to remove the entire uterus withthe tumor, and the extent of the operation became evi-dent only after the completion of the operation uponcareful examination of the specimen removed. Themore general use of improved vaginal specula aboutthe beginning of the nineteenth century enabled thesurgeons to make an earlier and more accurate diag-nosis in affections involving the vaginal portion ofthe uterus and rendered the organ more accessible

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to direct surgical intervention. To Osiander, of Got-tingen, more than to any one else, belongs the creditof popularizing the use of the vaginal speculum as adiagnostic resource and as an aid in operations uponthe lower segment of the uterus. As early as 1808 heresorted to the speculum and curved scissors in theremoval of uterine polypoid growths. To the samesurgeon also belongs the honor of having devisedand practiced for the first time, supravaginal ampu-tation of the carcinomatous cervix uteri. The firstoperation of this kind he performed in 1801. Thecarcinomatous cervix as large as a child’s head,which filled the vagina, was drawn through the vagi-nal outlet with a pair of Smellie’s obstetric forceps.The greater part of the tumor was torn away from thecervix, an accident which was followed by profusehemorrhage. As the uterus could no longer bedrawn down by the use of forceps, he inserted, withcurved needles, four traction sutures at the vaginalinsertion, placed at an equal distance apart. Theneedles and sutures were brought out through thecervical canal at a level corresponding with theinternal os. By gradual and careful traction uponthe sutures, the lower segment of the uterus wasbrought down to near the vaginal outlet. With Pott’sfistula knife the carcinomatous cervix was then am-putated. The hemorrhage, which was quite profuse,was controlled by applying a sponge dusted over witha styptic powder. The patient was convalescent fourweeks after the operation. The experience with thiscase led him to devise another method to enable himto render the uterus more accessible in cases in whichthe cervix was so much diseased that it could not bedrawn down by the use of forceps or traction sutures.This modification of his first procedure consisted ingrasping the cervix with the fingers of one hand andpressure of the hand of an assistant upon the abdom-inal wall above the uterus, and removal of the cervixwith curved scissors. For the purpose of removingcarcinomatous tissue from the cavity of the uterus

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he invented a curved chisel. The application ofSmellie’s obstetric forceps, as an aid in performing-vaginal hysterectomy, led to the invention of trac-tion forceps by Museux and Recamier. The reportsof Osiander’s attempts to remove the carcinomatousuterus through the vagina soon reached France, andhis operative procedures were modified by Dupuy-tren, Lisfranc and other French surgeons.

Dupuytren dragged the uterus toward the introitusvaginae with tenaculum forceps and amputated thecervix with curved scissors. Lisfranc exposed thecervix with the aid of a bivalve speculum, grasped itwith his tenaculum forceps, removed the speculumand by gradual traction brought the diseased partwithin easy reach. In the case of fungous growth heused the fingers of the left hand in making pressureagainst the blades of the forceps to prevent tearing.The amputation was made with a curved bistouryguided by the fingers of the left hand.

Hatin used a bivalve speculum and a traction for-ceps of his own invention, the teeth of which graspedthe interior of the uterus as well as the external sur-face of the vaginal portion. Forceps of a compli-cated structure for vaginal hysterectomy were also-devised by Canella and Colombat. The results ofpartial vaginal hysterectomy for carcinoma, as prac-ticed by Osiander and his immediate followers, wereas could be expected most discouraging. Osiander’scases, twenty-three in number, died sooner or laterafter the operation. The work of the French andItalian surgeons yielded no better results. In all ofthe cases the diagnosis was made and the operationsdone long after the disease had passed beyond thelimits of the parts removed. A speedy local recur-rence and death within a year after the operation wereconstant occurrences in all of the cases. The localand regional dissemination of carcinoma of the uteruswere not well known at that time and the operativeprocedure was usually limited to the part of thotumor and uterus which projected into the vagina.

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Dupuytren reported twenty-nine cases of vaginal re-moval of the carcinomatous cervix with fifteen deaths,but a later report by Pauly left only one recovery.The unsatisfactory results of the operation inducedDupuytren later to abandon it almost entirely and tosubstitute for it the potential cautery. The authenti-cated history of intentional complete extirpation ofthe uterus for carcinoma dates back to 1813. In1810, Wrisberg discussed the propriety and feasibil-ity of vaginal hysterectomy in a prize essay read be-fore the Vienna Royal Academy of Medicine. Twoyears later, Paletta removed the uterus through thevagina for carcinoma. He did not intend to removethe entire uterus, and the fact that the entire organhad been removed only became apparent after thecompletion of the operation by acareful examinationof the specimen removed.

The first deliberate and well-planned vaginal hys-terectomy for carcinoma was made in 1813 by J. C.M. Langenbeck, of Gottingen, the uncle of the latedistinguished surgeon B.von Langenbeck. The pa-per of Wrisberg and Paletta’s case encouraged him toundertake this difficult task. His patient was a Mrs.Oberschein, 50 years of age, the mother of severalchildren, with the general health but little impaired.She had suffered for some time with a lancinatingpain and a burning sensation in the region of theuterus. The uterus had gradually descended towardthe vaginal outlet. The suffering became so severethat the patient begged for an operation. Uterus pro-lapsed. On examination the cervix was found of astony hardness, nodular and ulcerated. The cervicalcanal very vascular, ulcerated and from it escaped abloody and exceedingly fetid discharge. The irritat-ing vaginal discharge had caused erosions of the ex-ternal genital organs. The ulceration of the cervicalcanal extended deeply into the cavity of the uterus.Digital exploration of the cervical canal and uterinecavity revealed an ulcerated surface with great indur-ation of the cervix and body of the uterus, and was

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followed by free hemorrhage. Through the invertedvagina the uterus could be felt as a firm body whichcould also be distinctly felt by rectal examination.As Langenbeck had no precedent to follow, he had todevise his own plan for the removal of the entireuterus upon which he had decided. The operationwas performed in the following manner: the patientwas placed with the pelvis upon the edge of the bedwith the thighs separated and the feet resting upontwo stools. The operator properly seated betweenthe thighs dissected the vagina from the cervix, thedissection was continueduntil the peritoneal envelopeof the uterus was reached. The dissection was madewith special care not to open the peritoneal cavity bydirecting the edge of the knife against the uterus;and separating the tissues as far as this could bedone with the handle of the scalpel. To reach thefundus of the uterus, the broad and round ligamentsand the Fallopian tubes had to be divided. In hisfirst report of this case he maintained that he re-moved both ovaries with the uterus, but from laterinformation gained by examination of the specimenand repeated examinations of the patient, he cor-rected this statement. Two round hard excrescencesconnected with the uterus gave rise to this wrong im-pression. The last part of the operation consistedin the subperitoneal enucleation of the fundus of theuterus. He had no one to assist him except a goutysurgeon who, when called upon to render muchneeded aid, could not rise from his chair. Towardthe end of the operation the hemorrhage becamealarming, when the following conversation, occurred:Langenbeck :

“Herr, so humpeln Sie dochjetzt herhei.”Assistant: “Ich kann nicht.” With severe hemorrhageand approaching collapse of the patient and no oneto assist him, prompt action on the part of the oper-ator became a matter of urgent necessity. With theleft hand, Langenbeck grasped and compressed thebleeding part, and with the right hand he passed aneedle armed with a ligature through the tissues be-

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hind the bleeding point. Having only one hand athis disposal the ligature was tied by grasping one endbetween the teeth and the other with the right hand.At this stage the patient appeared to be dying. Dash-ing cold water over the face revived her. The longwide vagina was now pushed in an upward directionby introducing the whole hand. Above the vaginawas a deep pocket, the walls of which were composedof the peritoneal investment of the uterus. Vaginaand peritoneal pouch were continuous with each otherand no opening into the peritoneal cavity could bedetected. Through the peritoneum the intestinalcoils could be distinctly felt. To prevent the inver-sion of this peritoneal bag by pressure against it ofthe intestines, a sponge was inserted. In spite of thecritical condition of the patient at the close of theoperation she made an uneventful recovery. If weremember that this, the first complete vaginal extir-pation of the carcinomatous uterus was made withoutan anesthetic, without assistance, and without theuse of hemostatic forceps, we can easily conceive thedifficulties which the operator encountered and granthim willingly the wrell merited and hard won honorof having established an important surgical opera-tion. Langenbeck’s trials, however, only began atthe completion of the operation. Death of the pa-tient would have brought him undeserved censure;her recovery excited the envy of his colleagues whichfollowed him to his grave.

The history of medicine and surgery is replete withsimilar incidents. The originator of every markedimprovement in medicine and surgery has, during hislifetime, received but little recognition for his laborson part of his colleagues. Professional jealousy hasalways selected for its target the men conspicuous bytheir honest, unselfish work. Langenbeck’s report ofhis successful operation aroused doubt and a bittercriticism among his contemporaries. Upon his re-turn from Cassel, where the operation was performed,he visited his friend Osiander, and related to him the

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particulars of the operation. Osiander doubted thepossibility of complete removal of the uterus andadnexa without opening the peritoneal cavity, as wasfirst claimed by Langenbeck, and said that he wouldadvise all of his patients who desired to have theuterus enucleated to consult Langenbeck.

Jorg doubted the veracity of the description of theoperation. Langenbeck invited his friends to exam-ine the patient after her recovery. The invitationwas accepted by Mende and von Siebold. Mendemade the examination twelve years after the opera-tion. The patient was in perfect health at that time,and the most careful examination satisfied Mendethat the entire uterus had been removed. Von Sie-bold made the examination Oct. 4, 1829. He in-dorsed the statements made by Mende in every re-spect. The testimony furnished by his trusted friendsdid not succeed in allaying the suspicions of a doubt-ful profession. Unfortunately the specimen was lostat the time of operation and could not, therefore, beutilized to verify and support Langenbeck’s claims.His assistant died soon after the operation, and histestimony was, therefore, not available to substan-tiate the operator’s position. Nothing was left forLangenbeck to do but to await patiently the oppor-tunity to fortify himself by the results of a post-mortem examination upon his patient. The patientdied of senile marasmus June 17, 1839, twenty-sixyears after the operation. The post-mortem wasmade by Dr. Neuber in the presence of three otherprominent physicians. The bladder, rectum and va-gina were removed together and placed in alcohol.No adhesions were found in the abdominal cavityand no signs of recurrence in any part of the body.The specimen is described in Max Langenbeck’s dis-sertation, “De totius uteri extirpatione,” Gottingen,1842. The upper part of the vagina and the emptyperitoneal pouch formed by the enucleation of theuterus were found inverted and formed a swelling inthe vagina which reached as far as the labia majora.

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Inspection of the peritoneal surface showed theFallopian tubes, their cut ends terminating in theperitoneal pouch. The inverted pouch appeared be-tween rectum and bladder as a globular depression,the surface of which did not show signs of scar tissueanywhere. Langenbeck places great stress on theperitoneal hernial protrusion, as a positive demon-stration that the uterus was enucleated without open-ing the peritoneal cavity. Both ovaries were foundin their normal relations with the fimbriated extrem-ities of the tubes. The description of the operationas given by Langenbeck is corroborated by the re-sults of the post-mortem, and the case will alwaysremain in history as the first intentional completevaginal extirpation of the uterus.

The second complete extirpation of the uterus pervaginam was performed by Sauter Jan. 28, 1822.Billroth and others have repeatedly wrongly quotedSauter’s name as the originator of the operation ofvaginal hysterectomy when, as the records show, hisoperation was performed nine years later. Sauter’scase differs from Langenbeck’s, in that the uteruswas not prolapsed and the peritoneal cavity wasfreely opened during the operation. The patient was50 years of age, and the cervix was found exten-sively ulcerated. Sauter intended to make an artifi-cial prolapse, as suggested by Wenzel, by the employ-ment of tenaculum forceps, and then remove theuterus by enucleation after the example of Langen-beck. In the attempt to bring the uterus down withthe curved index finger, the papillomatous excres-cences broke off, which gave rise to considerablehemorrhage. The vagina was now cut off from thecervix by a circular incision and another attemptmade to bring the uterus down by traction forceps,one blade of which was inserted into the cervicalcanal and the other placed upon one side of the cer-vix. Making in this manner strong traction uponthe uterus, the attempt was made to separate thebladder from the uterus by the finger and handle of

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scalpel, but this did not succeed. The piece of thecervix grasped with the forceps was torn off andafter working for half an hour he concluded to re-move the uterus in its position by the use of a curvedscalpel. Two fingers of the left hand served as aguide to the knife, and with it the uterus was de-tached from the bladder. The whole hand was theninserted into the peritoneal cavity, and with it thefundus of the uterus was seized. In the attempt todraw the uterus down, the intestines escaped and,after replacing them, a repetition of the same manip-ulation caused the same accident. He finally suc-ceeded in dragging the fundus of the uterus throughthe opening after which it was separated from theremaining attachments. The intestines did not pro-lapse after the removal of the uterus; urine escapedinvoluntarily. The opening contracted into a fun-nel-shaped space with the apex directed upward. Afew days later urine escaped through the vagina,showing that the bladder had been injured duringthe operation. After closure of the peritoneal cavitythe opening in the bladder was discovered. Thepatient recovered from the immediate effects of theoperation, but died on June 31 of the same year.

The post-mortem showed that the peritoneal cavitywas closed. A large opening in the posterior wall ofthe bladder communicated with the vagina. A num-ber of limited intestinal adhesions, ovaries in theirnormal location, tubes indistinct.

The experience with this case led Sauter to makethe following suggestions: horizontal position of thepatient; complete evacuation of rectum and bladder.Pressure by the hand of an assistant over the abdo-men above the pubes in the direction of the pelvis.Incision of vaginal vault between uterus and bladderwith scalpel with a short convex blade. Enlarge-ment of this opening around the whole cervix withthe same knife. Section of the broad ligaments closeto the uterus with curved scissors, guided by thefingers. Separation of uterus from the rectum with

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curved scissors; at last, bringing down of the uteruswith the whole hand and separation of remainingattachments.

The third complete vaginal extirpation of theuterus was made by Elias von Siebold, April 19,1823. The patient was 38 years old. To prevent in-jury to the bladder, a catheter was inserted and heldin place by an assistant. The same assistant com-pressed the abdomen above the pubes in the directionof the pelvis. The vaginal vault close to the cervixwas incised with Savigny’s fistula knife, first on theright side of the cervix, guided by the two fingers ofthe left hand. The opening was then enlarged suffi-ciently for the introduction of a finger; after this,section of the vaginal insertion all around and closeto the cervix; the broad ligaments were divided be-tween two fingers close to the uterus with a smallpair of polypus scissors. The uterus was now de-tached on the right side. To effect this also on theleft side, two fingers of the right hand were inserted,and using them as a guide the opposite side wasseparated with Savigny’s knife and Osiander’s chisel.A finger was now inserted into the cervix, and withanother pressure made from without, whereupon theremaining attachments of the vaginal vault on theright side were torn and the uterus slipped from be-tween the fingers. The intestines could be felt, butdid not prolapse. The uterus was now so high thatit could only be felt with the tips of the fingers.Attempts to bring it down by the insertion of theassistant’s fingers into the rectum and the use ofBoer’s excerebration forceps proved a failure. Theoperator satisfied himself that the only way in whichthe uterus could be brought down would be by theinsertion of the whole hand into the peritoneal cavity.As the vaginal entrance was too narrow, the peri-neum was incised. The opening in the vaginal vaulthad also to be enlarged, which was done withSavigny’s knife. The hand was now inserted, thefundus of the uterus grasped, and the organ drawn

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down into the vagina, after which the left broadligament was divided in the same manner as on theopposite side. Death sixty-five hours after the oper-ation. The post-mortem showed inflammation of thesmall intestines; fibrous exudations upon the peri-toneal surfaces ; rectum and bladder intact.

The second case, operated upon after Sauter’smethod, was by Holscher Feb. 5, 1824, a patient uponwhom Prael had performed previously Osiander’soperation. The patient was placed in the dorsalhorizontal position upon an obstetric chair. As theuterus could not be brought down with the hand anda brass needle twelve inches in length, the carcino-matous cervix was excised in order to reach thefundus of the uterus more readily. The vaginalvault and the broad ligaments were divided with anamputating knife, guided by two fingers, close to theuterus; first on one side, then on the other. Deathin less than twenty-four hours.

Wolff operated according to Sauter’s method May5, 1824. The patient was 60 years of age and insane.In this case the operation was greatly facilitated bycomplete prolapse of the carcinomatous uterus andinversion of the vagina. The incision of the vaginalvault was first made in front, then on both sides.The ligaments and tubes were then brought forwardand divided some distance from the uterus, afterwhich the uterus was separated from the rectum.The wound was sutured and the inverted vagina re-placed. Death two days after operation.

In 1830 Delpech combinedvaginal with abdominalhysterectomy, being five years later than Langen-beck’s first laparo-hysterectomy. At the vaginalvault Delpech incised the tissues between the bladderand cervix with a knife of his own invention. Theseparation of the loose connective tissue and thetearing of the peritoneum was done with the finger.After enlarging the opening sufficiently to insert twofingers the abdomen was opened above the pubes bymaking first an oval skin flap, after which the linea

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alba and peritoneum were incised. The operatorthen inserted a finger through the wound betweenuterus and bladder, which was used as a guide individing the broad ligaments, after which the uteruscould be sufficiently mobilized from above to severthe remaining attachments safely.

The fifth total extirpation of the uterus after Sau-ter was made by Elias von Siebold upon a patient 30years of age July 25, 1825. He rendered the uterusmore accessible prior to dividing the broad liga-ments by passing a silver needle with a steel pointarmed with a strong thread through the cervix, usingthe thread as a guy rope. The patient died two daysafter the operation.

The sixth total vaginal hysterectomy for carcinomawas made by Langenbeck upon a servant, 28 years ofage, August 5, 1825. As a preliminary step, the per-ineum was incised for the purpose of widening thevaginal opening sufficiently to permit the introduc-tion of the whole hand to grasp the uterus before thedivision of the right broad ligament. After placingthe index finger of the left hand in the vaginal vaultbetween the cervix and the rectum, it was utilized asa guide to Osiander’s hysterotome, with which an in-cision was made into the pouch of Douglas. Thisopening was dilated until the whole hand could beintroduced with which the fundus was grasped, andpressed in a downward direction, placing the broadligaments on the stretch. After section of the rightbroad ligament, the uterus could be brought downbeyond the rima pudendi, which made it easy to di-vide the remaining attachments. He places greatstress on opening the peritoneal cavity behind andnot in front of the uterus, as by doing so the bladderis exposed to less risk of being injured. He also in-sists that the large pelvic vessels should be protectedby making the incisions close to the uterus. As anadditional safeguard to protect the bladder andthe urethra, a catheter is held in proper position inthe bladder by an assistant. The hemorrhage was

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not severe. After the completion of the operation asponge was inserted into the vagina, and for theabdominal pain twenty leeches were applied withoutany material benefit following. The patient died onthe second day. The post-mortem revealed that thesmall intestines in the pelvis were covered by coagula-ted blood and a plastic exudate.

The seventh total vaginal extirpation of the uterusafter Sauter was made by Recamier, July 26, 1829,which, according to Gendrin, was the first operationof this kind in France. He modified Sauter’s pro-cedure only in so far that he ligated the uterinearte-ries in the lower part of the broad ligaments beforedividing them higher up. His patient was 50 yearsof age. With two tenaculum forceps he graduallybrought the carcinomatous cervix as far as the vulva.The vagina in front of the cervix was incised with aprobe-pointed bistoury (convex), and with the indexfinger the loose connective tissue between bladderand cervix separated as far as the peritoneum. Theopening was enlarged with the bistoury sufficientlyto enable him to insert two fingers; the peritonealcavity being opened, the fundus of the uterus wasgrasped and the upper part of the broad ligamentswas then divided one-third from above downward,without causing much hemorrhage, after which be-tween thumb and index finger the lower part of thebroad ligament, first on the right, and afterward onthe left side, was seized and with a curved tunneledneedle armed with a ligature, the ligament was trans-fixed and tied, thus securing the uterine arteries.The broad ligaments were then divided above theligature. The Uterus could now be brought out of thevagina and its attachments with the rectum wereeasily separated. The operation was completed intwenty minutes. Complete healing of the woundtwenty-seven days after operation.

The eighth vaginal extirpation of the entire uteruswas made by Langenbeck, August 18, 1829. This washis fourth complete extirpation of the uterus, and his

19

third per vaginam. It differed from his precedingcases in that the Douglas pouch was opened first andthe uterus removed piecemeal to the fundus, whichdid not appear to be diseased. Hemorrhage slight.The patient recovered from the immediate effects ofthe operation, but died on the eleventh day. Intes-tines reddened in places. Only a small fragment ofthe fundus remained. A rectal fistula with irregularmargins was found as the immediate cause of thefatal peritonitis.

The ninth complete vaginal removal of the uteruswas performed by Roux, Sept. 20, 1830. The patientwas 50 years old and the method employed Recamier’s.Death soon after the operation. The same surgeonperformed his second operation five days later, fol-lowing the same plan with a similar result.

The eleventh vaginal extirpation of the uterus wasperformed by Recamier Jan. 13, 1830, upon a woman35 years of age. At the completion of the operationthe intestines escaped into the pelvis; they were re-duced and the wound sutured. The patient died onthe second day from what was believed to be second-ary hemorrhage from the internal spermatic artery.

Blundell made the twelfth vaginal hysterectomyOct. 16, 1830. The woman was 47 years old. Cervixmuch enlarged and ulcerated. Patient’s generalhealth greatly impaired. The uterus was exposedwith the rectal speculum of Weiss, which was re-moved after grasping the cervix with tenaculum for-ceps. After bringing the uterus well down into thevagina a second forceps was applied, and by an as-sistant making traction upon both of them theuterus was brought within easy reach. An incisionwas made between the cervix and rectum with anordinary scalpel, after which the opening was en-larged with a probe-pointed bistoury. The next stepin the operation consisted in making a transverseincision in front of the cervix, separation of uterusfrom bladder, during which the latter was opened.The fundus of the uterus was grasped with the hand,

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and into it was inserted a sharp hook, with which itwas drawn in the direction of the vagina, after whichboth broad ligaments were severed. Hot fomenta-tions and thirty leeches relieved the abdominal pain.A return of the pain was met by the application oftwenty leeches. Four weeks after the operation thepatient was convalescent, but the vesico-vaginal fis-tula remained.

Dubled suggested that after liberating the cervixby vaginal incision, and after bringing the uteruswell down into the vagina by the employment oftenaculum forceps, the broad ligaments should beligated withoutprevious partial division, as was doneby Recamier. After this has been done the uterusis so freely movable that the diseased part can bereadily excised. He insisted that the operation shouldbe limited to the removal of diseased tissue. He car-ried this method into effect once,but his patient diedtwenty-four hours after the operation. In 1839Langenbeck performed a supravaginal amputationof the uterus for carcinoma. The patient was 44years old. The cervix was grasped with two volsel-lum forceps, and by continued traction it was broughtdown to the vulva. A circular incision around thecervix was made and the dissection carried upwardextraperitoneally as far as the body of the uterus,where the amputation was made. The patient madea good recovery, and at the time she left the hospitalthe wound was completely cicatrized.

I have given you this brief outline of the early his-tory of vaginal hysterectomy, to show the value of aretrospective view in these times of unrest in medi-cine and surgery. In the laudable ambition to de-vise new operative procedures,the surgeons of the pres-ent day often ignore the work of our forefathers. Newoperations are devised and described which were con-ceived and practiced, or, at least, recommended yearsago. Honesty and justice demand that credit shouldbe given to whom it belongs. From what I have saidit is evident that the uterus has been removed through

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the vagina for inversion and prolapse for mitre thana century. The credit for removing the carcinomat-ous cervix by the same route unquestionably belongsto Osiander. This operation was later improved byM. Langenbeck, who made, for the first time, the su-pravaginal amputation of the cervix for carcinoma in1830, an operation which was later revived and pop-ularized by Schroeder. Langenbeck and Sauter werethe pioneers in establishing vaginal hysterectomy forcarcinoma. Langenbeck enucleated the uterus in1813 and his patient recovered and finally died ofsenile marasmus at the age of 84. Sauter removedthe entire uterusper vaginam successfully in 1822 byan operation which, with some slight modifications, ispracticed to-day. Of the first twelve cases of com-plete vaginal hysterectomy, only three recovered, amortality of 75 per cent. Extraperitoneal enuclea-tion of the uterus has recently been described as anew operation, but those conversant with the historyof surgery will always link Langenbeck’s name withthe origin of this operation. The great mortalitywhich attended the first attempts to remove theuterus through the vagina were due to hemorrhageand infection. The improved means and techniquein prophylactic hemostasis and the introduction ofaseptic surgery encouraged Czerny to revive and im-prove vaginal hysterectomy in 1878. Since that timethe operation has been modified in various ways, andhas now become an established procedure in thetreatment of well selected cases of carcinoma of theuterus, but the honest student will always connectthe early history of this operation with the names ofOsiander, M. Langenbeck and Sauter.

LITERATURE ON THE EARLY HISTORY OF VAGINAL HYSTERECTOMYARRANGED IN CHRONOLOGICAL ORDER.

Paraeus: Opera Chirurgiea, 1594.Plater; ObservationumLibrl tres Basil, 1614.Henricus abHeer; Observationis Medicse OppidoRar®,l64s.Volkamerus: Historia uteri resectio ex virgine resecti, 1675.Von Sanden: De prolapsuuteri. Diss. Jen®, 1700.Blasius: Observationes medic® rarlores, 1700.Anselin; Observation inter essante sur uue extirpation totale d’ une

matrice sphaeOlOe. Jour de Med. Cblr. Pharm., etc., 1766.

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Quequet: Lettre coutenant quelques reflexiones sur une extirpationde la matrice. Jour, de M£d. Chir., Pharm., etc., 1767.

Wrisberg: Commentatlo de uteri mox post partum naturalem resec-tione non lethali, observatlone illustrata cum breviselma principiorumlethalitalis sciagraphia, 1787.

Monteggia: Annotazioni pratiche sopra imali veneri, 1794.Baudelocque: Recueil periodique de la Societe de Mt'dlcine de Paris,

1798.Alexander Hunter: Duncan’s Annals of Medicine for the year 1799.Bernhard: Eine Extirpation der Gebarmutter aus Umoissenhelt von

einer Hebamme verrichtet; nebst Bermerknngen liber die Extirpationder Gebiirmutter, als neuerdings empfohlnes Heilmittel des Gebiir-mutter Krebses. Lucina, Leipzig, 1802.

Struve: Einlge Ideen liber die Extlrpatio Uteri, als vielleicht enizigeHeilmittel des Gebarmutter-Krebses; nebst der Abblldung des Instru-ments. Jour, der praktischen Arzney Kunde und WunderarzneyKunde, 1803.

Lagresie: Observation sur nue extirpation de la matrice. Paris, 1805.Lazzari: Sull’extirpazione dell’utero cancerosa. Giorn.d. Soc. Med.

Chir. di Parma., 1812.Gutberlet; Siebold’s Journal, 1814,Carl Wenzel: Ueber die Krankheiten des Uterus, 1816.Osiander: Gottinger Gelehrte Anz.,1815.Klingberg: De extirpatione uteri. Havniae, 1817.Beyerl<s: Ueber den Krebs der Gerbarmutter. Prag., 1818.Sauter; Die giinzliche Extirpation der Gebiirmutter ohne selbst,

entstandeneu oder Rlinstlich bewirkter Vorfall vorgenommen undgliicklich vollflihrt mit nahererAnleitung, wie diese Operation gemachtwerdenkann. Constanz, 1822.

Murat et Patissier: De 1’ extirpation ou de 1’ amputation de la matrice.Diet, de Soc. MOd.,Paris, 1819.

Windsor: Medico-ChirurgicalTransactions, vol. x, 1819.Petit; Dictionaire des Sciences T. 31, p. 221,1819.Ramsbotham: Practical Observations in Midwifery, 1821.Paletta; Storia d’ una matrice amputata. Ann. Univ. di Med. Milano,

1822.Sauter; Die giinzliche Extirpation der carcinomatosen Gebiirmutter,

1822.Holscher; Beschreibung der volligeu Ausrottung einer nicht vorge-

fallenen carcinomatosen Gebiirmutter. Jour. f. Chir. u. Augenheil-kunde, 1824.

Yon Siebold: Beschreibung einer vollkommenen Extirpation derschirrhosen, nicht prolabirten Gebiirmutter, 1824.

Von Siebold: De scirro et carciuomate uteri, adjectis tribus totiusuteri extirpationis observationibus. Berolini, 1826.

Hesse; ZurGeschichte der Extirpation der Gebiirmutter. Allg. Med.Annalen. Leipzig, 1826.

Hatin : MOmoire sur un uoveau proc6d6 pour 1’ amputation du col dela matrice dans les affections cancereuses. Paris, 1827.

A. E. Siebold; Extirpation einer scirrhosen Gerbarmutter. Jour. f.Geburtshiilfe. 1828.

Avenal: Revue med. franc, et etrang., et Journalde Clinique, 1828.Blundell: SomeAccount of a Case in which the Uterus, in a state of

Malignant Ulceration was successfully removed. London Lancet, 1827.Bellini: Sopra un’ amputazione d’ un utero scirroso, idropico e invil-

uppato colla vescica orinaria. Ann. Univ. di Med. Milano, 1828.Blandin; Extirpation complete de 1’ uterus. Jour. hebd. de Med.,

Paris, 1829.Dupuytren : Extirpation de la matrice. Clinique. Paris, 1880.Recamier et Dubled: Nouvelle extirpation de la matrice. Arch.

Gen. de M<sd. Paris, 1830.Clement; Memoire sur 1’ extirpation de 1’ uterus. Paris, 1830.Evans ; A case of cirrhus uteri, with malignant ulceration of the

uterus, aud extirpation of that organ. London Lancet, 1830.Retzius: Om extirpatio uteri partialis. Tidskrift f. Liik. o Pharm.,

1832.Lisfranc: Gazette MMicale, 1834.

Sanchez de Toca: Observacion de nna extirpacion deuna porcionde la vejiga de la orina de gran parte de la vagina y de casi la totalidadde la matriz afectada de c&ncer, 801. de Med. Ciurg. y farm, Mad-rid, 1836.

Pauly: Maladies de 1’ uterus d’ apres les lecons clinique de M. Lis-tranc faites al’ hospital de la Pitid. Paris, 1836.

J. Williams: Extirpation of the Womb by Ligature. London Lan-cet, 1839.

Gebhard: Extlrpatio uteri carclnomatosi. Hamb. Zeitschrlft f. dieges Medecln. 1839.

Gely: Recherches sur P opportunity de P amputation de P utdrusdans le cas d’ abalessement ou de renversement, et sur le precede leplus convenable pour la pratiquer dans ces circumstances. Jour, dela sect, de M£d. Soc. Acad. Loire Inf. Nantes, 1839.

Velpeau: Cancer de la matrice, nouvelle extirpation presque com-plete de cet organe. Gazette de Hop. Paris, 1840.

Maisonueuve: Matrice cancer euse enleve£ completement. Bull.Soc Anat de Paris. 1841.

C. J. M. Langenbeck: Nosologie u. Therapie der CbirurgiscbenKrankheiten, B. 6, Gottingen, 1845. ,

Gregson; Extirpation of the Uterus. Lond. Med. Gaz., 1846.Kieter: Totale Extirpation des nlcht vorgefallenen krebshaft af

fleirten uterus. Med. ZeitungRusslands, 1848.Breslau: De totius uteri extirpatione. Monachi, 1852.