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Annals of Medical Practice

Ernest Watson Gushing

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ANNALS OF



GYNlCOLIIIi! m PEBUTRy



A MONTHLY REVIEW OF GYNECOLOGY, OBSTETRICS,
ABDOMINAL SURGERY, AND THE DISEASES OF CHILDREN.



Edited by
ERNEST W. CUSHING, M D., LL.D.,
CHARI^S G. CUMSTON, M. D., ROBERT W. HASTINGS, M. D.

• WITH THB COUxABORATIOM OF



Dk. APOSTOLI. Paris.

Prof. CHARPENTIER, Paris.

Dr. ANDREW F. CURRIER, New York.

Dr. B. DOLERIS. Paris.

Prof. GEO. F. BN6LEMANN, Boston

Prof. BARTON COOKE HIRST, Philadelphia.

Prof. L. EMMSTT HOLT, New Yoik.

Prof. M. D. MANN, Buffalo.

Prop. L. 8. McMURTRY, Louisville.

Dr. a. H. CORDIER, Kansas City.

X>BTBOIT OTNBCOLOOICAL SOCIETY.



Prof. W. M. POLK, New York.
Prof. POZZI, Paris.
Db. JOSEPH PRICE, Philadelphia.
Prof. M. SAENGER, Lelpsic.
Prof. H. N. POTTER, Burlington.
Prof. T. G. THOMAS, New York.
Prof. HAROLD WILLIAMS, Boston.
Prof. G. WINTER, Berlin.
Prof.* W. G. WYLIE, New York.
Dr. E. J. SENN, Chicago.
Prof. J. B. MURPHY, Chicago.

PHILADELPHIA PEDIATRIC SOCIETT.



Subscription, $3.00 a Year, in Advance. Single Copies, 26 Cents. *

VOLUME XII.
October, 1898, to Sepi'ember, 1899.



PUBLISHED BY

ANNALS OF GYNECOLOGY AND PEDIATRY,
168 Newbury Street, Boston.



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coptkiohted by

Ernest W. Gushing, M.D.

1899.



Press of Caustic A Olaflin,
Cambridge, Mass., U. S. ▲.



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Contributors to Volume XIL



Abt, Isaac A.
Atherton, Ella Blatbook
Barnks, Fancourt
Blailock, W. R.
Blumb, F.
Bouvee, J. Wesley
Brcmmall, J. D.
Campbell, O. Beverly
Crouch, G. w.
CuMSTON, Charles Greene
CusHiNO, Ernest W.

CUTTS, R. E.

Dean, Lee Wallace
Engblmann, Rosa
Fish, E. F.
Ford, J. Frank
Frttts, C. E.
Fuller, E. M.
GOODALE, J. L.

Hall, Ernest
Hand, Alfred Jr.
Hastings, Robert W.
HcMisTON, William H.
Kendall, Francis D.
Kernodle, O. p.



Lynds, J. G.
Matson, W. F.
May, J. Shepard
M'SWAIN, I. A.
Montgomery, E. E.
Morse, John Lovbtt
Norbury, Frank Parsons
Packard, Frederick A.
Painter, Charles F.
Pearce, F. Savary
Perby, Henry

PiLLSBURY, F. A.

Plummer« Edward M.
POPOPP, Wassil
Potter, Henry Nelson
Preston, J. H.
RiES, Emil
Sawyer, F. W.
ScoLLARD, John T.
Shearer, T. W.
Sherwood-Dunn, B.
Sprecht, John
Taylor, F. J.
Thornton, G. G.
Wiener, Alex. C.



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INDEX TO VOLUME XII.



GYNECOLOGY.

PAGE

Abdominal Celiotomy, Deaths after. . . 580
Abdominal Section under Cocaine An-
aesthesia for Retroverted Adherent

Uterus 511

Albuminuria after Ether Narcosis, A

Contribution to the Study of 437

Cancer of the Uterus, Operative Treat-
ment of 574

Care of Cases after Labor, The 20

Celiotomy for Conditions Complicat-
ing Typhoid Fever 571

Colloid Carcinoma of the Ovary 716

Curettement in Puerperal Fever . . 291, 375

Dermoid Cysts of the Ovary 796

Disorders of the Menopause 644

Eclampsia 162

Eclampsia, Treatment of 307

€k>norrhoeal Salpingitis, The Treat-
ment of 664

Graver Nerve Disturbances due to Or-
ganic Changes in the Genital Or-
gans, The 245

Hospital Abuse, Some Remarks on — 155

Hygiene of Pregnancy 302

Hysterectomy, Choice of Methods in. . 1
Indications for Csesarean Section as
compared with those for Symphysi-
otomy, Craniotomy and Premature

Induction of Labor 723

Inversion of the Puerperal Uterus 89

Maternal Dystocia, Some Causes of . . . 799

Notes from Clinical Lectures 27

Obstetric Practice, Twenty Years of . . 18

Operations During Pregnancy 504

Ovarian Tumor Removed during the

Acute Stage of Typhoid Fever 363

Pelvic Disease and Insanity 145

Premature Separation of the Placenta. 365
Puerperal Eclampsia, Symptomatol-
ogy of 311

Reports of Cases 757

Relation of Diseases of the Female
Generative Organs to Nervous and

Mental Affections, The 219

Rupture of the Uterus, Two cases of. . 385
Salicin Used in a Case of Puerperal

Fever 299

Stones in the Ovary 73

Surgical Diseases of the Liver 749

Tubercular Peritonitis, Laparotomy

for 804

Uterine Fibroma 499

Uterine Inflammation and Displace-
ments, Conservative Management of 11

Uterus, The 379

Uterus Bicomis, A Case of 83



PEDIATRY.

PAOK

Vaginal Hysterectomy for Epitheli-
oma Uteri, The Conditions of the
Genital Organs with Reference to . . 85
Vaginal Route in Preference to Ab-
dominal Section, 'Vhe Conditions
under which we are to Select the. . . 787
Acute Gastro Enteritis, Treatment of. 691
Acute Intussusception, Report of the

Case of an Infant with 316

Amylaceous Foods, The Digestion of. 393

Broncho-Pneumonia 61

Congenital Dislocation of the Hip in

Children 763

Conservative Diets in the Feeding of

the Sick and Convalescents 54

Cretinism and its Treatment 522

Diphtheria 677

Diphtheria, Medicinal Treatment of . . . 835
Duration of Intubation in Cured Diph-
theria Cases before and after the

Serum Treatment, The 330

Home Modification of Milk 465

Hygiene of the Public Schools 615

Intubation in Non-Diphtheritic Dis-
eases 404

Intubations Performed in the Diph-
theria Ward, Budapest, Report of. . . 195

Malnutrition in Infants 46

Membranous Croup and Intubation ... 65
Membranous Tonsilitis and Pharyn-
gitis of Influenza 771

O'Dwyer's Intubation, My Successes

with 119

Parenchymatous Inflammations of the
Mouth and Tongue, A Considera-

tionof 542,609

Pediatrics 390

Pushing Down Pseudo-Membrane in

O'Dwyer's Intubation 269

Reports of Cases 264, 321, 400, 492

Retropharyngeal Abscess, A Case of. . 260
Retropharyngeal Abscess and Retro-
pharyngeal Adenitis 544

Rhachitis: 830

Scarlet Fever Ill

Serum Therapy for Diphtheria 474

Traumatic Neuritis, A Case of 539

Urethritis in Male Children 189

Whooping-Cough, The Therapeutics
of 685

EDrfoMAL.

Bovine Tuberculosis 101

Cancer, Etiology of 456

Chorea of Pregnancy 107

Diphtheria and Intubation 452



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INDKX TO VOLUME XII.



Xlll



PAGE

Fibroid Tumors dining Pregnancy and

Labor, The Treatment of 38

Hemorrhage from Placenta Previa,

I iTreatmentof 105

Membranous Croup 43

Necessity of Pure Foods 187

Purulent Infection of the Integ^uments 186

Sugar of Milk to Shorten Labor 314

Symphysiotomy, Accidents and Com-
plications of 103

Twin Pregnancy and Eclampsia 453

Vaccination 387

SOCIEl'Y REPORTS.

American Association of Obstetricians
and Gynecologists 34, 94, 168

American Gynecological Society, May
23-25,1899 591

American Protologic Society, June 6,
7, 1899 671



PAOB

International Congress of Gynecology
and Obstetrics, Aug. 8-12, 1899 728

Philadelphia Pediatric Society, Oct.
11,1898 202

Philadelphia Pediatric Society, Nov.

8, 1898 280

Philadelphia Pediatric Society, Dec.

13,1898 343

Philadelphia Pediatric Society, Jan.

10,1899 422

Philadelphia Pediatric Society, Feb.

14,1899 494

Philadelphia Pediatric Society, Mar.

14,1899 561

Philadelphia Pediatric Society, Apr.

11,1899 625

Philadelphia Pediatric Society, May

9, 1899 707

Philadelphia Pediatric Society, June

13,1899 776



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Annals



OR

Gynecology and Pediatry

Vol. XII. OCTOBER, 1898. No. 1.

ORIGINAL COMMUNICATIONS

CHOICE OF METHODS IN HYSTERECTOMY.*

ERNEST W. GUSHING, M.D.

Six years ago a memorable discussion on hysterectomy took
place in this society, which led rapidly to a complete change in
the customary methods of performing this operation, and was the
starting-point of a great increase in the frequency with which it
was employed. It has seemed to me that it will not be without
interest now to discuss certain points of the technique of the op-
eration, and to compare different methods, in order to discover in
how far we agree in our procedures and to what extent a consen-
sus of opinion has been established. I therefore venture some
observations based on my own experience, in the hope of eliciting
the opinions of the other fellows of this society.

For the removal of the uterus we have to consider the follow-
ing methods, each of which is or may be preferable in certain
cases, so that it is of interest and importance to examine the indi-
cations which would cause either one or the other to be chosen in
a given case.

fa Extra-peritoneal

I. Snprapabic amputation < C Cervix caut'd and drained.

[b Infra-peritoneal i

I " closed without cautery.

*Read before the American Gynecological Society; Boston, 1898.



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ERNEST W. CUSHING.



II. Total extirpation



' AtMlomiDal



Vaginal



Vagina open (peritoneum open or

closed).
Vagina closed, choice of catgut or silk.

Combined operation, by vaginal and

abdominal incision.
Methods of Doyen, Martin, Richelot.

Clamps (morcellation).

Ligatures, abdomen drained or closed.



la. The extra-peritoneal treatment of the stump, by pins and
the serre-noeud or elastic constrictor has been, I presume, aban-
doned by all of us, except under exceptional circumstances.
Nevertheless, it is well to remember that it remains a precious
resource as an expedient of emergency, when, by reason of shock
or weakness from previous hemorrhage, it is advisable to termi-
nate an operation immediately. In some cases also of Porro's
operation, where the great vessels of the pregnant uterus are a
formidable factor, or where there has been a rupture of the uterus^
during labor and an operation of emergency is performed, this
method of treating the stump will always have certain advan-
tages for those who are familiar with it. The rising generation,
however, will have no opportunities of seeing this operation or
becoming familiar with its niceties, so that practically it is to be
classed with the abandoned methods.

16. The method of treating t;he stump intra-peritoneally by
dilating and cauterizing the cervical canal and draining it with
gauze, as first introduced by Eastman and recommended by Chro-
bak in 1892, was used by me in 1892 in some twelve cases with
the happiest results, but I have now abandoned it, and I think
that it has been generally given up, because in cases where there
is especial reason to fear infection from the cervical canal, it is
better to remove the whole cervix.

Careful experiments have shown that the healthy cervical canal
is not septic, and the preparation for hysterectomy now univer-
sally adopted includes thorough cleansing and disinfection of the
whole uterine cavity, so that when the opening of the stump is
closed by suture it is found safe and preferable not to cauterize it,
and thereby a better union is obtained.

If, when the stump is divided, the incision is made quite conical,
by traction on the body of the uterus and an oblique incision,
there is very little of the cervical mucous membrane left, and
there is a flap of uterine tissue in front and behind; I pass a long



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CHOICE OP METHODS IN HYSTERECTOMY. 5

curved probe through the canal from above downward and let an
assistant draw down through the canal a strip of iodoform gauze
wet in sublimate solution; this wipes all mucus and secretion from
the mucous membrane, including any secretion, which may have
descended from the uterus during the operation, and prevents any
infection of the cervical stump from the vagina after the opera-
tion. Even this procedure is not necessary in most cases. Then
I unite the flaps of the cervix with catgut in continuous suture,
above the mucous membrane of the canal, and, returning, unite
the peritoneum over the uterine tissue.

This seems the proper place to consider the indications for re-
moving the whole of the cervix, or for leaving some of it, a point
on which there is still much difference of opinion. The burden
of proof seems to be on those who advocate total extirpation, for it
prolongs the operation from ten minutes to half an hour, while
frequently there is some blood lost before the lateral and pos-
terior vaginal arteries are controlled. It may be added that the
field of operation is brought nearer the ureters, and accidents have
happened from this reason. It would seem that the opening of
the vagina would increase the chance of infection, in spite of the
most careful disinfection before the operation, and often when the
vagina is short and the abdominal walls are thick or rigid the dif-
ficulty of operation is perceptibly increased. It is claimed that
the pelvic floor is injured and the support of the intestines is
diminished if the cervix is removed, but of this I have had no
proof in my own experience. It is not to be denied, on the other
hand, that the cervix uteri is the seat of sexual sensation to a con-
siderable degree, and in many women it probably has a part to
fulfil in the sexual orgasm, so that it is desirable to leave it intact
unless there are indications for its removal.

Nevertheless, whenever hysterectomy is performed for malig-
nant disease of any part of the uterus, the extirpation should be
total; when the cervix itself is diseased, so that it is enlarged,
eroded or secreting profusely an imhealthy mucus or pus, it is
better to remove it; when the uterus is removed with the tubes
for tubercular conditions, or for gonorrhceal disease which mani-
festly involves the uterine mucous membrane, so that there is
presumably an infectious condition of the secretions, it is better
to perform total extirpation, especially as in these cases it is often
essential to provide for drainage. The same necessity for drain-



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4 ERNEST W. GUSHING.

age may be a reason for total hysterectomy in cases where sub-
peritoneal growth of fibroids has lifted up the peritoneum and left
large raw surfaces.

If it is decided to remove the whole of the cervix, instead of
amputating it, the incision is carried down at each side, keeping
close to the uterus, and pinching the lateral cervical arteries, until
the vagina is opened; or with a knife a median posterior incision
may be made, cutting against the cervix, until the vagina is
opened, or the same end can be reached by passing one blade of a
pair of scissors into the cervix and cutting through it posteriorly
until the posterior cul-de-sac is entered. I prefer the first method,
but it is immaterial. When the whole cervix has thus been re-
moved the operator has the choice of three methods. Either (1)
the vagina may be left wide open for drainage, or (2) the perito-
neum may be closed and the vaginal raw surfaces may be left
open, or (3) the vagina and peritoneum may be wholly closed.

Of these alternatives I would reject the second, which has only
the advantage that it permits ligatures to come away in due time,
after an annoying period of suppuration. It seems to me to be
one of the transition stages in the development of the operation,
and to be obsolete in the days of perfected technique. If the
vagina is to remain open, then a stitch on each side, using catgut,
will close the little lateral vessels, and may be so placed as to
cover the stumps of the uterine arteries with peritoneum and to
narrow somewhat, but not too much, the opening into the vagina.
It is well to split the posterior wall of the vagina for half or three-
quarters of an inch and whip it with catgut, so that the gauze
which is left for drainage lies at the bottom of the pelvis and not
at isome distance above it as is otherwise the case.

Nevertheless, in some cases where drainage is necessary, and
they are less frequent now than they used to seem some years ago,
I prefer to close the vaginal opening entirely, using the glass
drainage tube. This is only advisable, however, when the case is
in a place where I can watch it afterwards, and when I have a
nurse who is thoroughly trained in the care of the glass tube.

In my opinion the method of election is that of closing the
opening in the vagina with a continuous catgut suture, and after-
ward uniting the peritoneum with another continuous suture of
catgut, so that there is an unbroken line of union from the free
border of one broad ligament, across the pelvis, covering the



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CHOICE OF METHODS IN HYSTERECTOMY. 5

Stumps of the arteries and the line of union of the vagina, to the
free border of the other broad ligament. AVhen this is completed
there is no raw surface whatever in the pelvic cavity, there is no
need of drainage, and the convalescence is astonishingly smooth
and painless. It makes it easier to unite the peritoneum smooth-
ly, burying all raw surfaces, if instead of applying mass ligatures,
the broad ligaments are held by the fingers when severed, seizing
and tying each artery as it is cut. Of course if it is desired to
show in how small a time the uterus can be removed, the arteries
will be at first secured with catch forceps and only tied after the
uterus has been removed. Sometimes the difficulties of the op-
eration are such that this is the only practicable method, but I
think that on the whole it is better to tie each artery when it is
cut, for the time must be spent, in any case, before the abdomen
can be closed, and there is no real advantage in removing the
uterus in a given number of minutes, if the whole duration of the
operation is not thereby diminished. At any rate, when the
vagina is cut open it should be sewed together at once, being held
together meanwhile by double tenacula forceps, so that the chance
of infection from this source is minimized.

It is indispensable that in the preliminary cleansing of the
vagina and uterus all septic material shall have been removed or
sterilized; but, although this is easy to say, it is not always accom-
plished satisfactorily. In foul or suppurating cases it is well,
after curetting and washing out the uterus with sublimate solu-
tion, to pack the cavity with gauze, and even to sew up the cervix
with a few stitches, so that afterwards when the uterus is handled
it shall not discharge an infectious secretion into the vagina.
This can be done by an assistant so that the operator may keep his
hands clean.

This brings us to the consideration of the question whether it is
not well to proceed, after cleansing the vagina and uterine cavity,
to the separation of the vaginal tissues from the cervix and to tho
ligation of the uterine arteries from the vagina, in other words, to
the method known as the combined operation. I do not know of
any particular objection to this method, if the operator has to
clean out the vagina himself, or if he has an assistant who is com-
petent to liberate the cervix and tie the arteries. The fact that it
was formerly in rather extensive use, while the present methods
were in evolution, and that it has been abandoned by all operators



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6 EKNEST W. GUSHING.

of the first rank, leads me to place this method among the transi-
tion stages in the development of hysterectomy. In cases of
fibroids the finished surgeon will never have any difficulty in per-
forming the whole operation from the abdomen. In the excep-
tional cases where a huge fibroid polyp has been extruded and the
thick pedicle passes through the os uteri, it is better to tie and cut
the pedicle, pack the uterine cavity with gauze, sew up the os and
then proceed to the abdominal operation as usual.

In cases of pyosalpinx or other obscure conditions it is not well
to complicate matters by performing an important part of hys-
terectomy from the vagina, when on opening the abdomen it may
be found that the uterus with the appendages on one side may
be saved, or that it may be unnecessary or inconvenient to remove
the whole cervix.

In certain cases of cancer of the cervix, however, it may be a
great advantage to remove all the tissue which is apparently dis-
eased before opening the abdominal cavity, if it is thought prefer-
able to finish the operation by coeliotomy.

I should not have mentioned the combined method of operat-
ing, as a method of election, before this society, since I do not
think that it is practiced by any one present, were it not that il
has recently been recommended by a gentleman of great experi-
ence, and I have reason to think that it is still in use among gen-
eral surgeons. To facilitate the liberation of the cervix, and to
prevent hemorrhage, it has also been recommended to separate
the vagina from the cervix by the thermocautery, thus taking it
for granted that the vagina will not be united and that time will
be given for the silk ligatures to come away after weeks of suppu-
ration. Now, although this use of the thermocautery has been
highly recommended in performing vaginal hysterectomy with
the aid of clamps, precisely for the reason that it prevents the
edges of the vaginal wound from uniting too early and so prevent-
ing the escape of the inevitable discharges, and also for the reason



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