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 RG381 J49 Lectures on cancer 
 
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LECTURES 
 
 CANCER OF THE UTERUS 
 
 [Delivered at the Cancer Hospital, Brompton.] 
 
 WITH CASES. 
 
 FREDERIC BOWREMAN JESSETT, F.R.C.S., 
 
 SURGEON TO THE CANCER HOSPITAL, BROMPTON. 
 
 LONDON : 
 BAILLIERE, TINDALL AND COX, 
 
 20 & 21, KING WILLIAM STREET, STRAND. 
 1894. 
 

 
PREFACE. 
 
 These lectures, which were delivered at the Cancer Hospital, 
 Brompton, contain a brief description of the different forms 
 of malignant disease of the uterus, their symptoms and treat- 
 ment, with a pretty full account of the different operations 
 for the removal of disease, as it is found existing in different 
 parts of the organ. 
 
 The relative merits of the operation of vaginal hysterec- 
 tomy and supra -vaginal amputation of the os and cervix are 
 discussed : _ and in those cases in which neither of these 
 operations are applicable, the method of applying caustics 
 for the destruction of the disease, or the amelioration of 
 symptoms, is described. 
 
 In illustration of the treatment advocated, short notes of 
 cases operated upon by the author are appended. 
 
 I, Buckingham Palace Mansions, S.W., 
 September, 1894. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/lecturesoncancerOOjess 
 
LECTURES ON CANCER OF THE UTERUS. 
 
 DELIVERED AT THE CANCER HOSPITAL, BROMPTON. 
 
 By Frederic Bowreman Jessett, F.R.C.S., 
 
 Surgeon to the Cancer Hospital, Brompton. 
 
 LECTURE L 
 
 I HAVE chosen the subject of cancer of the uterus for 
 my lectures, as it is one of the most frequent forms in 
 which the disease comes under our notice, and those who 
 have had any experience of the disease will agree that it is 
 one of the most fearful scourges that suffering women are 
 heir to. I would urge upon you then, with all the force in 
 my power the importance of most careful examination of 
 all cases, and special attention to the smallest detail and 
 symptom which may lead you to suspect the possibility of 
 the existence of the disease. 
 
 Age plays an important part, as cancer of the uterus, like 
 cancer of other parts of the body, is far more commonly 
 met with between the ages of forty and fifty than at any 
 other period. This period is that in which all the organs 
 appear to commence to degenerate or atrophy, and it 
 would seem to be that time of life when cancer is specially 
 prone to take root in the system. 
 
 At the Cancer Hospital out of 860 cases of cancer which 
 I have tabulated, 476 occurred between the ages of forty 
 and sixty years of age. 
 
 
 20—30 
 
 30—40 
 
 40—50 
 
 50 — 60 
 
 over 60 
 
 Total. 
 
 Author ... 
 Godson . 
 
 31 
 30 
 
 104 
 165 
 
 223 
 233 
 
 253 
 136 
 
 249 
 36 
 
 860 
 600 
 
 Total... 
 
 61 
 
 269 
 
 456 
 
 389 
 
 28s 
 
 1460 
 
 Dr. Godson, in six hundred cases he collected at St. 
 Bartholomew's Hospital, has noticed the same average'; 
 age, therefore, is an important factor, and in any case of a 
 woman suffering from haemorrhage between the periods, 
 between the ages of thirty and sixty, a vaginal examination 
 should be insisted upon. 
 
In the first place I propose to discuss some of the remote 
 symptoms which are often present, and frequently are 
 treated for more or less lengthened periods without any 
 suspicion of uterine mischief existing. When attention is, 
 however, attracted to the uterus, some condition such as 
 ante- or retro-flexion, erosion of the os, metritis or in- 
 cipient carcinoma is discovered : by treating these con- 
 ditions the symptoms which have been so long a source of 
 trouble disappear. 
 
 Now I have no doubt that many cases of incipient 
 granular erosion of the cervix or chronic inflammatory 
 conditions of the endometrium are frequent precursors of 
 cancer, and that by neglecting these minor diseases grave 
 mischief may result which will endanger the patient's life. 
 
 In studying the symptoms of uterine troubles one cannot 
 but be struck at the similarity of the symptoms displayed 
 by patients, whether they are suff"ering from chronic 
 metritis, endometritis, fibro-myoma, or early stage of cancer. 
 Possibly it will be only by close examination that any 
 diff"erence in character or intensity is discovered. And yet, 
 although the general group of symptoms are so alike, it 
 will be found that each form of disease has its own par- 
 ticular symptom more prominently developed — i.e., haemor- 
 rhage in cases of myomata; nervous disorders and pain in 
 those of displacements ; and leucorrhoeal discharge and 
 haemorrhage in erosion of the os and cancer. 
 
 As, then, cancer of the uterus is often accompanied by 
 displacement, endometritis, and occasionally with fibroids, 
 it is readily seen what difiiculties there are to contend with 
 in arriving at an accurate diagnosis. 
 
 LeucorrhcEal discharge is, I believe, the earliest symptom 
 present in cancer of the uterus, whether commencing at 
 the fundus or at the cervical canal, and this can be readily 
 understood when one remembers that cancer commences 
 in the epithelium lining, the uterine cavity and the glands 
 of the mucous membrane, so that the irritation, the result 
 of the disease, causes a certain amount of endometritis 
 resulting in a catarrhal condition of the mucous membrane 
 lining the cervix, or the uterine cavity. 
 
 Leucorrhoea, then, is an exaggerated and morbid altera- 
 tion of the physiological vaginal and uterine secretions ; 
 for, normally, there is always a certain amount of secretion 
 from the mucous men^brane lining of both the vagina and 
 
uterus, when this becomes increased or purulent then the 
 term leucorrhoea is applied to it. Vaginal leucorrhoea is 
 a fluid milky secretion which only stiffens linen slightly: 
 it is acid in reaction. Uterine leucorrhoea is yellowish 
 white and only slightly viscid : that from the cervix is 
 gelatinous ; normally, it resembles white of egg. It stif- 
 fens linen considerably : it is alkaline in reaction. 
 
 It is with the uterine leucorrhcea that we are at present 
 interested and no doubt this is the earliest evidence or 
 symptom that mischief of some sort exists in the uterine 
 cavity. Now leucorrhoea in itself is only a consequence 
 of some catarrhal condition of the mucous membrane 
 lining the cervix or cavity of the uterus, and, on examina- 
 tion with the speculum, will be seen exuding from the 
 canal as a viscid gelatinous liquid. But if after treatment 
 this does not abate, then it may be suspected that some- 
 thing more than simple catarrh exists. In cases of 
 carcinoma it will be noticed that the secretion becomes 
 more liquid and yellowish, and with occasionally streaks 
 of blood mixed with it, later a further change takes place 
 and the discharge becomes watery, sanious, and badly 
 smelling. 
 
 Besides this local early manifestion there are several 
 other symptoms, the result of reflex irritation, which mani- 
 fest themselves in neighbouring organs. These symptoms 
 doubtless exist in nearly all affections of the uterus to a 
 greater or less extent, but they must be borne in mind, as 
 it is by having attention called to the uterine affection and 
 by careful examination that we may hope to recognize this 
 terrible disease in its early stage and so be able to deal 
 with it when there is the possibility of doing so. 
 
 The most common symptom of these neighbouring 
 organs is connected with the bladder. Women experience 
 a frequent desire to micturate, and frequently suffer from 
 vesical tenesmus : and occasionally cystitis supervenes. 
 
 Constipation is frequently complained of, this is the 
 result of the constantly deferred action, as the act of 
 defecation is accompanied by much pain, therefore patients 
 get in the habit of restraining themselves as much as 
 possible. 
 
 Uterine dyspepsia is a most constant symptom of uterine 
 irritation, and one the importance of which cannot be 
 over-estimated. The overlooking of this symptom has 
 
often resulted in grave disaster — and yet how easy it is to 
 connect the disease of the uterus to the digestive system, 
 if it is only borne in mind the close relation of one to the 
 other through the sympathetic nervous supply. If it is 
 remembered the close connection between the gastric 
 irritation, as exemplified by nausea and vomiting, connected 
 with the early stages of pregnancy, it can be readily under- 
 stood how constant uterine irritation may be the cause of 
 reflex digestive disorders. 
 
 This subject has been recognised by gynaecologists now 
 for a length of time, and it is no uncommon thing for a 
 patient to consult one after they have been the round of 
 the general physician, and been treated for a considerable 
 period for ordinary dyspepsia, when on careful examination 
 it is found that she is suffering from extensive erosion of 
 the OS ; flexion of the uterus ; or metritis, and possibly 
 carcinoma. 
 
 I will not detain you by alluding to other reflex symptoms, 
 such as respiratory reflexes ; reflexes of the cerebral and 
 peripheral nervous systems, neuroses of genital origin, but 
 these must be always borne in mind as possibly being due 
 to some uterine trouble. 
 
 So much then for the early general and local symptoms 
 which may result from uterine irritation, and which, if 
 thoroughly recognised, may be the means of our discovering 
 cancer of the organ before it has advanced so far as to be 
 beyond our control. 
 
 It will be convenient here to define exactly what is 
 meant by the term cancer, and for this purpose I will adopt 
 the definition of Dr. John Williams, as given to it by one 
 school of pathology. 
 
 Cancer then is a new growth, possessing malignant 
 properties — i.e., it possesses the power of invading neigh- 
 bouring tissues, and of reproducing itself in the form of 
 secondary growths in other and distant parts. By accepting 
 this definition it will be seen to embrace all forms of 
 malignant disease, whether carcinoma, sarcoma, or epith- 
 elioma. 
 
 Sarcoma is a growth of the connective tissue type, and 
 invariably, I believe, commences in the structure of the 
 connective tissue in the body of the uterus. Although 
 this form of malignant disease is usually present in young 
 subjects, when affecting different parts of the body, in the 
 
7 
 
 uterus it is very frequently found in elderly patients. 
 During the last few months I have had three patients suf- 
 fering from this form of disease, all of whom were over 
 sixty years of age. I believe that sarcoma attacks the 
 uterus much more frequently than has generally been 
 thought. Since I have taken especial interest in uterine 
 cancer I have found that quite a third or fourth of the cases 
 of malignant disease of the body of the uterus are 
 sarcoma. 
 
 Carcinoma. — All carcinomata contain epithelial elements 
 and are formed of epithelial cells bound together by a 
 network of vascular connective tissue, or to put it in 
 another way, all these tumours are formed of bands of 
 connective tissue which interlace with each other, forming 
 a network or framework between the meshes of which are 
 packed groups of epithelial cells of different shapes. 
 Carcinoma usually commences in the cervical canal or body 
 of the uterus, either from the lining mucous membrane or 
 the glands in the mucous membrane. 
 
 Epithelioma is of rare occurrence and when present 
 always originates on the external os. 
 
 It will considerably facilitate the description of the 
 different forms of cancer as they affect the organ, and 
 indeed it is necessary for an intelligible description to 
 divide the uterus into three portions — viz., the vaginal por- 
 tion ; the cervical portion ; and the body. 
 
 The vaginal portion embraces that portion only which its 
 name implies, and is limited above by a line drawn from 
 the external orifice to the insertion into the vagina. This 
 part is covered with squamous celled epithelium, this form 
 of epithelium ends at the external orifice, and then the 
 transitional commences, which, as Dr. John Williams 
 observes, often disappears and is replaced by a glandular 
 erosion which is covered with columnar epithelium, and 
 the columnar epithelium meets the squamous without the 
 interposition of the transitional form. 
 
 The cervical portion is limited below by the vaginal 
 portion, and above by a line drawn transversely through 
 the inner orifice. At this point the columnar epithelium 
 ends and the tubular glands characteristic of the decidua 
 begins. 
 
 The body of the uterus is that portion which is situated 
 above the cervix. Cancer, as it affects either of these parts, 
 
may present different characters, and may be classified 
 as scirrhus, encephaloid, medullary, epithelioma and 
 sarcoma, but it is not so much of the different forms of 
 cancer that I propose to speak, as to the parts in which 
 they originate and are located. 
 
 Cancer of the vaginal portion. — The disease is rarely 
 found to originate on this portion of the organ, this has 
 been fully borne out by the researches of Ruge Veit, 
 John Williams, Schroeder, Leopold and others ; although 
 the disease frequently invades the part by growth from the 
 cervical portion. 
 
 When it does exist I believe it nearly always originates 
 in some crack or erosion of the os which has been the 
 source of irritation. Patients suffering from cancer of the 
 portio vaginalis often have no symptoms whatever to lead 
 them to suspect the presence of the disease. Although 
 they undoubtedly have suffered from leucorrhceal dis- 
 charge for some considerable time. Yet this is such a 
 common complaint with women that they take but little 
 notice of it, and probably the first, or at any rate, the 
 usual symptom that attracts attention is haemorrhage, some- 
 times occurring spontaneously, sometimes after coitus, and 
 yet, many of the cases, when an examination is m.ade, are 
 found to be suffering from extensive disease, perhaps the 
 walls of the vagina being implicated. 
 
 If these cases had been examined at an earlier stage how 
 much could have been done, possibly erosion of the os or 
 fissures is the precursor in many of these, and how difficult 
 it is in such cases even by most careful examination to 
 decide when the erosion or fissure has taken on a cancerous 
 action, but yet how important it is for the welfare of the 
 patient that a correct diagnosis should be formed. And 
 here I would counsel you that in all cases of doubt to 
 remove a small portion for microscopic examination, and 
 if any doubt exist as to its true nature to at once perform 
 amputation of the neck of the uterus well above the 
 diseased parts. Practically, there is no risk in such an 
 operation, and I am of opinion that in all cases wheer 
 there is extensive erosion and cracking with thickening and 
 infiltration of the tissues of the cervix, that it is good 
 practice to remove it by amputation. The form of cancel 
 that is most commonly found attacking the portio vaginalis 
 is " epithelioma." 
 
Cervical portion. — We must now pass on to the con- 
 sideration of the disease as it attacks the cervical portion. 
 Here again it is most difficult clinically to differentiate 
 between an erosion, an adenoma, and carcinoma. In 
 what way clinically does one differ from the other } Dr. 
 John Williams describes an erosion as an extension of 
 mucous membrane of the cervical canal through the ex- 
 ternal orifice on to the lips, which are, in health, covered 
 with stratified epithelium. In some cases, no doubt, simple 
 hypertrophy of the mucous membrane of the canal re- 
 sembles an erosion. A true erosion, however, is described 
 as consisting of a structure like that of the mucous 
 membrane of the cervix placed on a surface which, in 
 health, is covered by squamous epithelium. It may be and 
 often is associated with hypertrophy of the mucous 
 membrane at the lower part of the canal. It contains 
 glands lined by columnar epithelium, and its surface is 
 covered by epithelium of the same character. 
 
 An erosion differs from cancer in that the epithelium on 
 its surface and lining, its glands consists of a single layer 
 and assumes no aberrant forms ; and from an adenoma of 
 the cervix in that the glands are comparatively superficial. 
 It will be seen then that in erosion the glands are con- 
 siderably increased in size and number, and I have but 
 little doubt that many cases of cancer of the cervix 
 commence as erosion, for not only do these glands 
 increase in number, but they also develop in places where 
 glands do not exist in health. 
 
 It is in the epithelium lining of these glands that the 
 chief changes take place in cancer, the cells which consti- 
 tute a single layer in health become stratified and increased 
 considerably in number, often breaking down the whole 
 lumen of the gland. The nuclei in the cells proliferate, 
 and the cells become altered in shape, then become 
 elongated, and assume an appearance of strings of cells 
 dipping downwards into the deeper structures, and the 
 epithelium itself becomes flattened, so as to have the 
 appearance almost of squamous-celled epithelium. And 
 it is only by tracing it to its origin that the true character 
 can be ascertained. 
 
 The part at which cancer of the cervix commences is in 
 the cervical glands. Dr. John Williams goes so far as to 
 say he has never seen a case commencing in the epithelium 
 
of the surface, but it may and undoubtedly does frequently 
 commence in the glands close to the surface, and when 
 these cases come under our notice they are so far ad- 
 vanced that it is most difficult to say where the disease 
 commenced. The part of the canal which is usually 
 attacked first is the lower half, although of course it may 
 commence at any spot. The posterior lip appears to be 
 attacked more frequently than the anterior, and it is of the 
 utmost importance to remember that no matter in what 
 manner the disease originates, it, I believe, invariably 
 extends downwards and outwards at first, although it may 
 grow in an upward direction later. 
 
 The symptoms of both these forms of disease are most 
 obscure and more frequently than not, it is far advanced 
 before advice is sought, and yet how many cases there are 
 who consult their ordinary medical attendant for leu- 
 corrhoeal discharge or perhaps slight haemorrhage, and 
 are provided with an astringent injection and a tonic, and 
 are sent away being assured that their symptoms are 
 entirely due to weakness, and the poor deluded woman 
 continues to take her medicine and use the injection in the 
 fond hope that all will come well presently. The discharge, 
 however, continues ; after a time weight and dull pain in 
 the back are complained of with forcing bearing down 
 pains. The bladder becomes irritable, and a constant 
 uneasiness in the epigastric region is noticed, which is 
 attributed to indigestion. Then usually the discharge is 
 noticed to be tinged with blood, or there may be a sudden 
 rush of blood or metrorrhagia. Even then often no 
 examination is made and the patient is treated with steel 
 and ergot, presently the discharge is noticed to be rather 
 offensive, and the sense of forcing pain, weight and pains 
 in the legs, more frequently the left than the right, and 
 haemorrhage after coitus draws more especial attention to 
 the local condition, and at last a vaginal examination is 
 made. And then it is that the grave nature of the disease 
 is discovered. And only too often it is found to have 
 extended to such a degree that the uterus is fixed, probably 
 the vaginal walls invaded, and it is too late to do anything 
 more than adopt palliative measures for the relief of pain 
 and the keeping parts as clean as possible. 
 
 Such is the sad picture that is constantly brought before 
 our notice both privately and at this hospital. Let me 
 
II 
 
 again impress upon you therefore the paramount import- 
 ance of early examination of these poor women when they 
 consult you, suffering from symptoms of uterine mischief. 
 
 Now in cases of cancer of either of these two portions 
 of the uterus, i.e., the porlio vaginalis or the cervix ; if 
 early examination is made the disease is readily recognised, 
 or at any rate such a condition of things is found that 
 would justify one in removing a small portion for micros- 
 copical examination when the nature of the disease will be 
 at once ascertained — and in such a case by free removal 
 of the parts by supra-vaginal amputation the disease may 
 be thoroughly removed. 
 
 During the last five years I have performed supra-vaginal 
 amputation for cancer of the cervix on over fifty cases of 
 either cancer of the portio vaginalis or the cervix, with a 
 death-rate of four per cent., and it will be instructive here 
 to give you short histories of some of these cases selecting 
 two typical cases of the disease as it attacks these parts 
 separately. The cancerous nature of which were con- 
 firmed by microscopic examination. 
 
 Case I. — Mrs. , set. at sixty-one, married ; several 
 
 children. Vagina free, the external os is ulcerated, the 
 ulceration extending into the cervical canal. Bleeds freely 
 on examination ; much induration. On July 26, 1889, I 
 performed supra-vaginal amputation of the cervix. The 
 patient made an excellent recovery, and remained free 
 from the disease until her death, which took place some 
 two years afterwards from bronchitis. By the courtesy of 
 Dr. McCaskie, whose patient she was, I was enabled to get 
 the uterus, which contained not the slightest trace of 
 disease. 
 
 Case 2. — Mrs. H., set. at thirty-nine, four children. 
 Always had rather hard labours. Has had leucorrhoeal 
 discharge since last child, two years ago. The discharge 
 has always been yellowish, and latterly with occasional 
 streaks of blood. Has had constant wearying bearing 
 down pains. Menstrual flow quite regular. No extra pain 
 at these times. No pain on coitus, latterly, however, has 
 noticed slight bleeding afterwards, but took little notice of 
 it until about three months ago when she consulted her 
 medical man. No examination was made, and she was 
 ordered an astringent injection which at first appeared to 
 give her relief. She continued this until coming to consult 
 
me, her reason for doing so being that after coitus she had 
 rather a sharp attack of haemorrhage. On vaginal ex- 
 amination the posterior lip is found to be thickened and 
 rough, deep ulceration extending into cervix. Bleeds 
 readily on touch. Vagina free. Uterus movable. Supra- 
 vaginal amputation was performed on December 2, i88g. 
 There was some free haemorrhage which was arrested by 
 plugging. Wound healed well and the patient has no 
 recurrence at present time, over five years after operation. 
 These are two typical cases of many that have presented 
 themselves, and illustrate well what I have said. 
 
 CANCER OF THE BODY. 
 
 We will now pass on to the important consideration of 
 cancer of the body of the uterus, and this is the more 
 important, as often even with the most careful examination 
 the disease may be overlooked. 
 
 Happily the disease attacks this part of the uterus much 
 less frequently than the vaginal portion or cervix, and at 
 one time it was even questioned if the body ever was 
 attacked primarily. Now my experience leads me to think 
 that the body is much more frequently the seat of the 
 disease than is generally supposed. 
 
 I have operated on six cases for cancer of the body of 
 the uterus, and now present for your inspection the speci- 
 mens I have removed. Perhaps the most typical case is 
 
 that of Emily C , set. sixty-two, single. Admitted into 
 
 the Cancer Hospital February loth, 1894, suffering from 
 cancer of the fundus. Family history : Mother died of 
 cancer of the liver. The patient has had a discharge for 
 some twelve months. About six months ago it became 
 very offensive, and occasionally tinged with blood. She 
 complained of pain at the lower part of abdomen and 
 back ; had lost flesh considerably, although she never was 
 very stout. On November 27th, 1893, she went into the 
 Samaritan Hospital, when the cervical canal was dilated, 
 and the uterus explored ; some soft growth was scraped 
 away for microscopical examination. 
 
 On admission she was seen to be a very emaciated-looking 
 woman. On vaginal examination it was found that she 
 was suffering from a badly smelling discharge ; the vagina 
 was very small. The cervix feels healthy, and the uterus 
 is found to be freely movable, and not appreciably enlarged. 
 
T3 
 
 Examination causes much pain. A foul discharge is seen 
 to be exuding through the os. I performed vaginal hys- 
 terectomy upon this patient on February 20th, and she has 
 made a very good recovery, leaving the Hospital five weeks 
 after operation. 
 
 Another case, Frances St. J , was very instructive, as 
 
 showing the presence of the disease quite in its early state 
 and complication with fibroids. She was aged forty-four 
 years ; married ; four children. Admitted into the Hos- 
 pital on January 4th, 1894. The patient merely complained 
 of great pain in lower part of abdomen. Very slight, 
 rather faintly smelling, discharge. By vaginal examination 
 the cervix feels hard, and os thickened and eroded. Body 
 of uterus enlarged ; some bosses felt on posterior surface 
 of uterus. Sound passes 3^ inches. Vaginal hysterectomy 
 was performed on January gth. The patient made an 
 excellent recovery, and was discharged three weeks after 
 operation. 
 
 On opening the uterus there were evidences of early 
 carcinoma, Mr. Plimmer, pathologist to the Hospital, 
 has made careful microscopic examination of this, and 
 pronounced it to be early adenoid carcinoma. 
 
 Here then was a case that was seen quite in its early 
 stage, and cancer was suspected, hence the operation of 
 hysterectomy was performed and the diagnosis confirmed, 
 and the operation justified by the microscope. 
 
 The disease usually attacks the body of the uterus after 
 the menopause ; in fact, I have not met with one case 
 occurring before this period. Mr. John Williams' expe- 
 rience tallies with mine in this respect. Ruge and Veil 
 have reported two cases as occurring under the age of 
 forty : one was between forty and fifty ; six were between 
 fifty and sixty, and seven were between sixty and seventy. 
 Dr. John Williams reports three cases : one fifty-three 
 years of age, one fifty-four, and one sixty-nine. My cases 
 were one forty-three, one forty- four, one fifty-two, one 
 fifty-five, one sixty-two, and one sixty-three. In all these 
 cases I removed the uterus, and all made good recoveries. 
 So that it is important to remember that cancer of the 
 body of the uterus is rare before the menopause. 
 
 The first symptom that usually draws attention to the 
 disease is haemorrhage ; women after the menopause notice 
 bleeding, at first slight or in gushes, or only tinging the 
 
T4 
 
 discharge which probably they have had, but attributed to 
 "whites" for some considerable period. They often 
 take no notice of it, thinking that it is " nature" shewing 
 itself again ; some women are rather pleased at it, sup- 
 posing themselves to be becoming young again. Always 
 take it as a most serious symptom, therefore, if a woman 
 consult you after the menopause suffering from haemorr- 
 hage : always insist on a vaginal examination, and do not 
 be deluded because you find the os and cervix normal, but 
 thoroughly examine bi-manually, and if there is much pain 
 in the examination do not hesitate to make a thorough 
 examination under an anaesthetic, as it is only by such an 
 examination that you can hope to make a correct diagnosis 
 and at the same time ascertain if the case is one in which 
 an operation for total extirpation is justifiable. Another 
 symptom is pain, often a forcing bearing-down pain, lasting 
 sometimes for a considerable time, at others for a shorter 
 period. The jolting of a cab or omnibus often increases 
 this pain which is due, I suspect, to the contraction of the 
 uterus endeavouring to expel the growth. 
 
 In all cases of doubt it is well, when the patient is under 
 an anaesthetic, to dilate the cervix and remove with a 
 currette a portion of the contents of the uterus, for it must 
 not be forgotten that haemorrhage, pain, and offensive 
 discharge from the uterus, may be occasioned by endo- 
 metritis of old age, and is also present in certain forms of 
 ulceration of the cavity which is looked upon as lupus. 
 
 As to the origin of cancer of the body it is, no doubt, 
 often associated with fibroids. In the case I have just 
 mentioned to you, there were a number of fibroids present. 
 Ruge and Veit think the disease occasionally commences 
 in polypi of the uterus. Dr. John Williams has recorded 
 such a case in which a mucous polypi was removed from 
 the cervix while undergoing the process of becoming a 
 cancer. Or the disease may develop from the first in the 
 form of a polypi. In the case I saw with Dr. Gross, the 
 patient, aet. 62, had bleeding and discharge, and it was, on 
 examination, concluded she had cancer of the body of the 
 uterus. On examination under an anaesthetic I found the 
 uterus full of a pulpy mass which readily broke down under 
 the finger and had all the appearance of blood clot, this 
 being removed I came down upon two what seemed to be 
 distinct polypi, these I removed. The patient rapidly 
 
^5 
 
 convalesced. I had these growths examined microsco- 
 pically and they were pronounced to be small round- 
 celled sarcoma. 
 
 This patient had a rapid recurrence and a few months 
 after I removed the uterus and appendages per vaginam. 
 The patient again convalesced quickly, but the disease 
 recurred in the broad ligament in a few months and the 
 patient died. 
 
 Cancer, when originating in this manner, is usually 
 circumscribed and will be found on section of the organ to 
 be attached to some part of the uterine cavity by its pedicle 
 the growth itself fungating from this and filling the cavity. 
 
 The disease, however, is often diffuse, in which case it 
 nearly always commences on the glands or, it may be, in 
 the epithelium lining the cavity. The uterus is usually 
 enlarged and elongated. As the disease extends the walls 
 of the uterus become involved and the muscular coat 
 becomes thinner and thinner, and then the uterine peri- 
 toneum becomes adherent to the viscera, and it is no 
 uncommon thing for a loop of intestine to be adherent. 
 The disease, as it extends, does not invade the cervix until 
 quite late, but it would appear to extend to the broad 
 ligament, and often to the bladder and rectum, the organ 
 becoming completely fixed. In a case I had recently 
 under my care such was the case : the disease extended to 
 the bladder first preventing the power of expulsion of the 
 urine, the patient was obliged to have her urine constantly 
 drawn. It then apparently caused blockage of one ureter 
 with consequent hypertrophy of the opposite kidney. After 
 a few months the disease extended and evidently blocked 
 the mouth of the remaining ureter, with the result of 
 urjemia, coma, and death. 
 
 TREATMENT. 
 
 We will now pass on to the treatment of the disease as 
 it is found attacking the diff"erent parts of the organ, and 
 here the advantage of dividing the organ into sections is 
 most manifest as it is obvious the treatment of cancer of 
 the portio vaginalis, the cervix and body being free, must 
 differ essentially from treatment of the disease when the 
 body alone is attacked. 
 
 The treatment of cancer of the uterus is a subject which 
 has occupied the attention of both physicians and surgeons 
 
i6 
 
 from time immemorial, and although many suggestions 
 have been made, no permanent benefit has been obtained, 
 and these poor suffering women who were the victims of 
 this terrible disease perished unrelieved. 
 
 I have examined the uteri of a large number of cases, 
 who have died in the hospital, with a view of ascertaining 
 the cause of death, and found that a large number died from 
 uraemic poisoning, caused by obstruction to the ureters, by 
 growth or pressure of the disease, others died from 
 secondary growths, and some died from septic mischief and 
 exhaustion. I was much struck, however, by the limited 
 extent of the disease in the body of the uterus. In many 
 cases, which from clinical examination, it was supposed the 
 whole organ was affected, it was found that the disease 
 was limited to the external os and cervix, but it had 
 extended into the cellular tissue around the cervix, impli- 
 cating the ureters, or had implicated the vaginal wall, in 
 many advanced cases invading the bladder in front or the 
 rectum behind. 
 
 Acting upon the information thus obtained, I came to 
 the conclusion that for practical purposes it would be well 
 to divide the disease into four divisions : — 
 
 1. Those cases in which the disease is limited to the 
 portio vaginalis. 
 
 2. Those cases in which the cervix and body of uterus 
 is implicated. The organ being readily drawn down to the 
 vulva. 
 
 3. Those cases in which the disease has extended beyond 
 the uterine substance into the surrounding cellular tissue, 
 causing the viscus to be more or less fixed, and perhaps the 
 roof of the vagina slightly involved. 
 
 4. Those cases in which the disease extends beyond the 
 above limits, invading the vagina, and possibly the bladder 
 or rectum, or indeed both of these organs. 
 
 The rational manner of treating cancer of the uterus 
 must be based upon the same lines as treating the disease 
 when attacking any other organ of body. If a patient 
 consults one suffering from cancer of the breast, tongue or 
 elsewhere, free extirpation of the disease is advised. 
 
 The same rule must hold good then in the advice you 
 give for the treatment of cancer of the uterus. Free 
 removal. 
 
17 
 
 Of course, if on examination the parts are fixed, the 
 vaginal wall implicated and the disease has infiltrated into 
 the cellular tissues around the cervix, then the removal by 
 extirpation becomes inadvisable if not impossible, in the 
 same manner as cancer of the breast, where the mammary 
 gland is fixed to the chest wall and the axillary and 
 cervical glands invaded, the question arises can anything 
 be done in these cases, and here I should be guided 
 entirely by the extent of the disease. If the bladder and 
 rectum appear to be free from infection, I think a great 
 deal may be done by the judicious application of caustics 
 or the galvano-cautery. 
 
 If, however, these viscus are affected or the whole parts 
 are so absolutely fixed as to render the application of 
 these caustics to be fraught with great uncertainty, then 
 there is nothing to be done but to keep the parts as clean 
 as possible by injection with some antiseptic fluid. I prefer 
 sanitas fluid, the keeping the bowels quietly opened and 
 the free administration of opiates by the mouth, or hypo- 
 dermically if the pain is very excessive, or in the form of 
 suppositories. 
 
 The method of syringing the vagina is a matter of great 
 importance. I do not consider the placing the patient on 
 a bed pan and using the vaginal tube sufficient, as there is 
 always a lot of debris, and sloughs which this will not 
 remove. But I consider the syringing, at least once or 
 twice a day, should be done through a Fergusson's speculum 
 and then with pieces of cotton wool on uterine forceps, 
 the cavity should be wiped thoroughly out, by this means 
 a large amount of badly smelling debris will be dislodged. 
 Then the cavity should be thoroughly dusted with iodoform 
 or a tampon of wool soaked in equal parts of pinus 
 canadensis and glycerine, or smeared over with an ointment 
 composed of 
 
 Sanitas oil Si. 
 
 Zinc chlorid gr. x. 
 
 Vaseline § i. 
 
 should be introduced into the cavity. 
 
 This should be removed night and morning ; the vagina 
 being douched on each occasion, and the cavity wiped out 
 with cotton-wool before the introduction of a fresh tam- 
 pon. By adopting this simple plan of treatment the 
 sloughs become dislodged, and a clean ulcerated surface 
 disclosed, B 
 
1 8 
 
 In most of these cases benefit will be derived by the 
 application of a strong solution of chromic acid ( 3 ii. — § i.) 
 to all the diseased surface after the parts have been 
 thoroughly dried, being careful not to allow the solution to 
 run on to the healthy tissues ; these can be protected by 
 the application of pieces of cotton wool soaked in a 
 saturated solution of carbonate of soda, and finally some 
 tampons should be placed in the vagina and left until the 
 next day. 
 
 All offensive smell disappears, and the pain and bladder 
 irritation are relieved. 
 
 The disease will be considerably retarded in its growth, 
 and the patient's appetite will return, and the general 
 health improve, owing doubtless to the non-absorption of 
 the poisonous discharge. 
 
 Perfect rest should be insisted on, and the general 
 health attended to by the administration of appropriate 
 tonics, attention to the bowels, and if pain is present and 
 prevents sleep, small doses of morphia may be advan- 
 tageously given. 
 
 Many extreme cases treated in this manner have ex- 
 pressed themselves as greatly relieved, and have left the 
 hospital much improved in general health. 
 
 The question next arises, Can nothing be done for this 
 terrible disease by the means of drugs ? Numerous drugs 
 have been credited with ameliorating the suffering of 
 patients, retarding the disease, and, indeed, in some cases 
 of curing it. I need not go through the whole category 
 of these remedies ; it would be weariness and certainly 
 not profitable. 
 
 The drug that hitherto has been credited with giving the 
 best results is chian turpentine, as suggested by Dr. Clay. 
 This drug, like all others, has been the source of much 
 disappointment, but still in many cases if it has not 
 arrested the disease, it certainly appears to have the power 
 of relieving pain. Dr. Clay has reported several cases in , 
 which he claims that cure has been effected. 
 
 The emulsion, as suggested by Dr. Clay, is very nau- 
 seous, and the turpentine has been made in the form of 
 pills, but if these are not freshly made they become so 
 hard that I think they merely pass through the intestinal 
 canal unaltered, 
 
19 
 
 Pyoktanin is another remedy which has been credited 
 with the property of curing cancer ; its supposed power 
 seems to be based upon the manner in which it attacks the 
 cells when used for staining microscopic specimens. It is 
 ordered to be injected into the cancerous mass, and also 
 to be taken internally. 
 
 M. Narm (Bucharest) read a paper on the treatment of 
 malignant tumours of the mouth, parotid gland, cheek, 
 and of the uterus by injection of a solution of violet of 
 methyl (i-ioo). Each day he injected from half a drachm 
 to three drachms of the liquid into the morbid tissue. Out 
 of 25 cases treated ten were claimed to be cured, while the 
 remainder were much benefited. The liquid, while 
 destroying the morbid elements, did not have any effect on 
 the healthy parts, differing thus from caustics, which act 
 on sound and diseased tissue alike. 
 
 I. have used this in some cases, and in one or two small 
 cases of sarcoma it certainly appeared to have a good 
 effect in one case in particular, a small recurrent sarcoma 
 in the cheek. The disease totally disappeared, and did 
 not return for over a year, when it recurred and was again 
 injected, and has not returned since some two years ago. 
 For uterine cancer I have packed the cavity in some cases 
 with gauze soaked in solution of pyoktanin, but it did not 
 appear to do much if any good, and it played such havoc 
 with the linen that I abandoned it. 
 
 I have of late, however, been employing some tabloids 
 which have been made for me, consisting of a mixture of 
 chian turpentine, ichthyol and pyoktanin. I have treated 
 several cases with these tabloids, and I must confess with 
 much benefit, and I am looking forward with great interest, 
 hope and expectation that these tabloids if they do not 
 cure these cases, at any rate will greatly relieve them. 
 Time will show. 
 
 In cases not quite so advanced as these I have just 
 alluded to much good may be hoped for by placing the 
 patient under an anaesthetic and freely applying a galvano 
 or thermo-cautery. 
 
 If the disease is limited to the vaginal portion of the 
 uterus it may be attacked by the galvano -cautery, passing 
 the needles into different parts of the disease, tolerably close 
 together, over and over again. The action of the galvano- 
 cautery, as thus applied, it must be remembered, is by 
 
direct cautery action, and not by the destruction of the 
 cells by the galvanic current. 
 
 I adopted this method of applying the cautery in 
 the first instance, in the hopes that the cells might be 
 destroyed by galvanic action without causing necrosis of 
 the tissues by the cautery action but was disappointed. 
 This form of application has, however, I think this advan- 
 tage, that the needles can be inserted to an ascertainable 
 depth into the diseased parts and the cautery action extends 
 to a very limited extent beyond that. This form of treat- 
 ment may be adopted in certain forms of cancer of the os 
 or cervix by introducing one electrode into the cervical 
 canal and then inserting the needle of the other electrode 
 into the diseased tissues around the cervix. The cautery 
 action is again exemplified hereby, in some cases, the os 
 and cervix sloughing out in the course of a few days. 
 
 Paquelin's cautery, I think, is a better form of application 
 for such cases if the cautery is to be adopted at all. The 
 patient being placed under an anaesthetic is put in a litho- 
 tomy position by means of Clover's crutch and the diseased 
 parts thoroughly scraped with a sharp spoon, or curette, 
 then the cautery is applied at a white heat. This applica- 
 tion may have to be applied several times and is not very 
 satisfactory. 
 
 In all cases I would suggest a long course of treatment 
 by the administration of the tabloids I have already referred 
 to, as it is quite possible, if the system can be generally 
 affected by the drugs, it may be the means of destroying 
 any outlying cells which may have been left. 
 
 The best form of treatment, undoubtedly, in all cases 
 in which the disease is limited to the portio-vaginalis, is, to 
 perform amputation of the affected parts by cutting through 
 the vaginal mucous membrane around the os, well free of 
 the disease, and separating the cervix from the surrounding 
 cellular tissues and amputating through the cervix. 
 
 Should the cervical canal be slightly implicated, the am- 
 putation can be carried higher by removing a cone-shaped 
 piece from the uterus above the internal os. 
 
 Should the cervix be infiltrated with the disease then 
 nothing short of vaginal hysterectomy or removing the 
 entire organ should be sanctioned. 
 
 The mortality of this operation in experienced hands 
 is not nearly so great as was supposed, and I believe with 
 
21 
 
 care that the mortality may be reduced to about 5 to 8 per 
 per cent. In twenty-seven cases of complete removal of 
 the uterus per vaginam which I have performed, I have 
 only lost two cases from the operation. When it 
 is remembered we are dealing with a disease which 
 is sure to end fatally if left alone, and not only so, 
 but the death is usually associated with the most terrible 
 suifering, I say this mortality is not worth consideration. 
 The important question to be considered is, undoubtedly, 
 how many of these poor creatures are cured, and how 
 many have recurrence of the disease and at what periods ? 
 These are questions which I propose to discuss in my next 
 lecture together with the details of the performance of 
 these operations. 
 
22 
 
 LECTURE II. 
 
 THE TREATMENT OF UTERINE CANCER BY OPERATION OR 
 
 OTHERWISE, WITH SPECIAL REFERENCE TO VAGINAL 
 
 HYSTERECTOMY. 
 
 In my last lecture I narrated to you the history and 
 symptoms of cancer of the uterus as it attacks different 
 parts of the organ. I further discussed the palliative treat- 
 ment of those cases in which the disease invades the vagina 
 and surrounding cellular tissues, the uterus being quite fixed, 
 so that any attempt at a radical operation must be of 
 necessity impracticable. 
 
 To-day I propose (ist) to narrate to you the form of 
 treatment which has been fairly successful in my hands of 
 those cases in which the disease has extended beyond the 
 uterine substance into the cellular tissues around the cervix, 
 thus causing the viscus to be more or less fixed, and perhaps 
 the roof of the vagina slightly involved. 
 
 I have tried numerous forms of treatment in these cases 
 that have been suggested and practised by different surgeons, 
 but one after the other I have ceased to adopt them, as in 
 none did any good result, and in many the disease seemed 
 to be stimulated to increase with greater rapidity than if left 
 alone. 
 
 It was with feelings of despair that I entered my uterine 
 ward, feeling that all I could do was to alleviate the sufferings 
 of some of the poor women who occupied the beds, but as 
 to any further aid I felt I was utterly powerless to assist 
 them. 
 
 Of late, however, a new era seems to have opened up, 
 and I now undertake the treatment of many of these cases 
 with full hope and expectation of, in some instances, eradi- 
 cating the disease, and in others of considerably retarding 
 it, and in all, of giving immense relief from pain and an 
 improvement in general health. 
 
 In adopting the treatment I am about to describe, I was 
 in the first instance struck by the fact that in many of the 
 most advanced cases of uterine cancer which died, the body 
 
23 
 
 of the uterus was often apparently free from disease. The 
 disease appeared to have commenced in the cervical canal 
 and then extended downward to the external os, and then 
 eaten its way through the cervix and extended laterally into 
 the cellular tissues surrounding it, and from thence along 
 the broad ligaments. 
 
 Now, if the disease were attacked before it extended 
 along the broad ligaments, and before the bladder or rectum 
 was affected, I thought I saw my way to cope with it. In 
 the first place the thorough curetting away of all the soft 
 diseased tissues was imperative. Then to find some form 
 of caustic, and method of applying it to the cavity caused 
 by the removal of the disease, so as to burn deeply into the 
 surrounding tissues into which the disease might have 
 invaded. 
 
 With respect to the curetting, I found the curettes by 
 themselves were ill-adapted to the purpose, as they removed 
 the diseased tissues unevenly. I next turned my attention 
 to Bell's dredgers, but found these did not fulfil all I wished, 
 as they were too pliable and their calibre was too small. 
 The idea then occurred to me if I could have an instrument 
 constructed somewhat after the principle of Bell's dredger, 
 that I could increase the size of by means of a screw in the 
 handle, and furnished with watch-spring knives so shaped as 
 to enable me to scrape out the contents of the uterus by 
 simole rotations, I should have made a considerable advance, 
 and should be able to accomplish all I required. Such an 
 instrument was made for me by Messrs. Maw, Son, and 
 Thompson, and, as you will see, is worked by means of the 
 screw at the end of the handle. By means of this screw 
 the blades, which when first introduced lie fiat on the central 
 rod, are made gradually to expand until they represent an 
 area of about one and a half inches in diameter. Here, 
 then, I was furnished with an instrument by means of which 
 I was enabled to remove the whole contents of the uterus 
 with comparative ease, and, as the blades are not too sharp, 
 no mischief can be done with them, and very little bleeding 
 follows its use. 
 
 The next question which arose was the form of caustic 
 and the method of its application. And here I followed in 
 the steps of Drs. Marion Sims and Heywood Smith. I 
 
24 
 
 adopted the use of absorbent wool soaked in a saturated 
 solution of chloride of zinc and then dried. The caustic 
 applied in this form had the advantage of being readily 
 packed. Before packing the uterus all bleeding must be 
 arrested, as it is essential that the raw surfaces should be 
 fairly dry before applying the caustic. The best method of 
 arresting the haemorrhage is to apply locally sponges wrung 
 out in very hot water, or, failing this, apply a sponge which 
 has been soaked in tincture of matico. When the oozing 
 has been sufficiently arrested, the chloride uf zinc wool is 
 packed in small pieces, firmly, so as to completely fill the 
 cavity. The preparation of this wool is difficult, and of 
 late I have been in the habit of using the chloride of zinc 
 paste freshly made, and then applying a ring pessary with 
 thin rubber diaphragm over the opening, so as to ensure the 
 full action of the caustic to the vaginal border. A dry wool 
 tampon is next applied to the opening in the vagina, and 
 lastly the vagina is packed with tampons soaked in a strong 
 solution of carbonate of soda. These tampons can be 
 removed the day following the operation, but the chloride 
 of zinc packing must not be removed for at least three days. 
 This wool is most conveniently removed by Marion Sims's 
 screw, which is a long straight rod with a very fine double 
 screw at the top. After the removal of the plugs the 
 vagina and uterus must be kept constantly syringed out 
 with some antiseptic solution, preferably either solution 
 of iodine or carbolic acid, through a full-sized Fergusson's 
 speculum. 
 
 As a rule, the slough caused by the caustic comes away 
 in about ten days or a fortnight, when a healthy granulating 
 surface is left. Should there be any suspicious spot, it will 
 be well to pack the cavity again. This can be readily done 
 without an anaesthetic through a full-sized Fergusson's 
 speculum. 
 
 Should any nodule be seen projecting it can be readily 
 destroyed by injecting a few drops of solution of chromic 
 acid ( 3 ii - 5 i) into it, this causes the nodule to shrivel up 
 and come away in a few days. 
 
 In a case recently under my care, after the slough had 
 detached itself, a large boss was seen growing rapidly from 
 the posterior wall of the vagina, this I injected with five 
 
25 
 
 drops of chromic acid solution and it dried up and became 
 detached in about five days. 
 
 The following two out of a number of cases, all of which 
 were markedly benefited by the treatment, will illustrate the 
 usefulness of this method. 
 
 Case I. — Mrs. S , aged seventy, consulted me on 
 
 Feb. 3rd, 1892, suffering from carcinoma of the cervix uteri. 
 
 I performed supra-vaginal amputation of the os and 
 cervix. The patient made an excellent recovery. In 
 November of the same year, there being some bleeding 
 from the uterus, I examined her and found recurrence of the 
 disease extending into the uterine cavity. The patient 
 suffered much pain and discomfort. Considering the age of 
 the patient, I did not think the removal of the entire uterus 
 justifiable. Moreover, the uterus was somewhat fixed by the 
 extension of the disease. I therefore, with the assistance of 
 Dr. Heywood Smith, thoroughly scraped and dredged the 
 uterine cavity, and then packed with chloride of zinc wool, 
 as above described. At the end of a fortnight I removed a 
 thick slough, which represented a cast of the inside of the 
 organ. The uterus and vagina were kept constantly syringed 
 out three times a day with a solution of carbolic acid. The 
 patient made an excellent recovery, and had no local return 
 of the disease. She, however, died in May, 1893, from 
 secondary growths in the liver and lungs. 
 
 The following case, for the notes of which I am indebted 
 to Mr. West, my house surgeon, have been treated in the 
 Cancer Hospital during the last year. 
 
 Case 2. — Rebecca H , aged thirty-three, married, six 
 
 children, one miscarriage, admitted into Burdett-Coutts 
 Ward, on January 4th, 1893, complaining of pain in the 
 back and left iliac region, and of discharge from vagina, 
 which patient has noticed for the last ten months. 
 
 Menstruation has been irregular during that period, severe 
 floodings alternating with amenorrhoea ; has lost much flesh. 
 
 Present condition. — There is a mushroom-shaped soft 
 growth in the situation of the vaginal portion of the cervix 
 which has ulcerated. The growth extends on to the posterioi 
 vaginal wall. The uterus is somewhat fixed 
 
26 
 
 On January 24th, 1893, under ether, all the soft parts of 
 the growth was scraped away with the dredger, and the 
 whole of the interior of the uterus was also scraped, which 
 left a crater-like cavity. The cavity was then plugged with 
 dry wool, which had previously been soaked in a saturated 
 solution of zinc chloride and allowed to dry. A dry tampon 
 of wool with a string tied to it was then passed and the 
 vagina filled with plugs squeezed out of a strong solution of 
 bicarbonate of soda. 
 
 The patient had very little pain after the application of 
 the caustic. 
 
 January 25M : All the vaginal tampons removed except 
 one and the vagina well douched out three times a day. 
 
 January 2']th — The zinc chloride wool removed from the 
 uterine cavity. The uterus well douched out through a 
 Fergusson's speculum. 
 
 'January z'Sih : Much offensive discharge : otherwise 
 patient experiences little discomfort. Temperature 99.8'' F. 
 Vagina well syringed out through a Fergussons's speculum 
 three times a day with i to 40 carbolic. 
 
 January ^oth : A whitish slough came away from the 
 vagina, being a cast of the ulcerated cavity. 
 
 February \st: Patient much better; no discharge to speak 
 of; and states she suffers no pain. On vaginal examination 
 the cavity feels soft and healthy. 
 
 February xT^th : Patient discharged; feels much better in 
 general health ; no pain or discharge to speak of. 
 
 August 2nd: She has reported herself from time to time 
 and still keeps in good health. 
 
 There is a firm cicatrix at seat of cauterization. No 
 discharge. 
 
 This patient is still attending ai the out-patient department 
 and there is no recurrence of the disease in in situ. 
 
 The treatment of such cases as these is naturally attended 
 with much anxiety, and, indeed, uncertainty. The caustic 
 must be most carefully applied on account of the many im- 
 portant parts that are in close proximity : the bladder, the 
 rectum, and the ureters. In two of my cases the slough 
 extended into the rectum, causing a recto-vaginal fistula. 
 
27 
 
 It is very extraordinary how little pain these patients suffer 
 from the application of the caustic, and the day following 
 operation patients who have suffered much before the appli- 
 cation express themselves as free from pain. 
 
 I will next discuss the treatment of those cases in which 
 the disease is limited to the portio vaginalis or cervix, the 
 body being free the vaginal walls not implicated and the 
 uterus freely movable. In these cases the operation of 
 supra-vaginal amputation gives excellent results. 
 
 SUPRA-VAGINAL AMPUTATION. 
 
 In December, 1892, I read a paper at the British Gynae- 
 cological Society giving details of twenty-five cases of 
 supra vaginal amputation of the cervix for uterine cancer. 
 Of these fifteen recovered and have presented themselves 
 for examination from time to time since. All these are still 
 well and free from any recurrence, the time which has elap- 
 sed since the operation on these cases varies from three to 
 eight years. One case remained free from the disease for 
 two years when recurrence occurred. In five cases recurrence 
 took place within one year. Two cases were lost sight of 
 but were free from recurrence when last seen; and two died, 
 one from pelvic cellulitis and the other from the extent 
 of the disease. This last case should not strictly be in- 
 cluded in the series as the disease was far too extensive to 
 allow of simple supra-vaginal amputation. 
 
 Seven cases out of the twenty-five which either died or 
 had early recurrence were clearly not benefited by the 
 operations, or in other words they were unsuitable for this 
 special form of operation. Six of these seven cases, from 
 my later experience might, I think, have been benefited had 
 vaginal hysterectomy been performed. 
 
 Since reporting these cases I have operated in a similar 
 manner upon thirty-three others with the same percentage of 
 deaths, viz. : 4 per cent. 
 
 Now, before proceeding further, it will be well to define 
 the meaning of the term supra-vaginal amputation : It must 
 be thoroughly understood that it is not merely the amputa- 
 tion through the cervix for the removal of the external os 
 and lower part of the cervix, but for the removal of the 
 entire cervix, with, in most cases, a large cone shaped piece 
 
28 
 
 out of the body of the uterus. I am quite in accord with 
 John Williams, Schroeder, and Hofmeir, whose statistics go 
 conclusively, I think, to show that when carcinoma of the 
 uterus is seen early, and the disease is limited to the vaginal 
 portion of the organ, supra-vaginal amputation is all that is 
 necessary, and it is useless to run the extra risk of total extir- 
 pation. Gusserow gives the mortality after supra-vaginal 
 amputation when performed by the knife as 9*09 per cent. 
 
 METHOD OF PERFORMING THE OPERATION. 
 
 The patient being placed in the lithotomy position, the 
 legs supported by a Clover's crutch, the vagina is first 
 thoroughly douched out with carbolic solution (1-40) and 
 perfectly cleansed by means of stick sponges. Two Sim's 
 specula are now introduced, and the edges of the diseased 
 OS seized by two or more pair of Vulsella forceps, by means 
 of which the diseased cervix is drawn well down through 
 the vulva. A sound is next passed into the bladder to 
 define its relation to the cervix. The mucous membrane is 
 to be divided as far away from the disease as possible, 
 usually, I think, a line just where the mucous membrane of 
 the vaginal wall ceases, and it becomes reflected over the 
 neck of the uterus is the best, the scissors, which, by the 
 by, I always use, should be long and strong and bent on the 
 flat, the points, after the mucous membrane is divided, 
 should be kept just in the muscular tissues of the uterus as 
 near to the outer border as possible, and the scissors carried 
 by a succession of short snips evenly round and round the 
 part to be excised. In this way there is no difficulty in 
 arriving at the internal os, here is the crucial point, and if it 
 is found necessary to go beyond this great care wifl have to 
 be exercised, as the point of the scissors may readily cut 
 through into the peritoneum. Some surgeons lay great stress 
 on this danger, but as a matter of fact in performing supra- 
 vaginal amputation, Douglas's pouch is much more fre- 
 quently opened than not. Some surgeons suggest that this 
 should be stitched up. I never adopt this practice, and 
 have hitherto seen no bad result follow. Strong traction 
 should be used upon the os with Vulsellum forceps, and it 
 is often well to introduce a sound into the uterus to serve as 
 a guide. Any bleeding points should be caught and tied. 
 If, however, as is occasionally the case, the haemorrhage is 
 
29 
 
 profuse, the uterine arteries must be secured ; ttiis is rarely 
 necessary. In some cases in which the haemorrhage pro- 
 ceeds from points situated in the uterine wall it will be 
 found most difficult to ligature the vessels ; in such cases 
 one or two or three plans may be adopted, one is to leave the 
 forceps hanging for a period of twenty-four hours, the other 
 to pack the wound with gauze soaked in a tincture of 
 matico, or to apply Paquelion cautery freely. 
 
 In cases of women who have not arrived at the climacteric 
 period, and in which the operation has not extended beyond 
 the internal os, the endometrium not being entirely 
 removed, it is always wise to introduce a vulcanite stem into 
 the uterine cavity, and to have this removed and replaced 
 each day, thus preventing the wound on healing from closing 
 the outlet of the uterus, as in many cases might take place. 
 By not attending to this precaution I have seen, in several 
 instances, very great discomfort, and, indeed, risk to life. 
 
 After the operation is completed, and all bleeding arrested, 
 I am in the habit of passing a stout long chromic gut suture 
 through the anterior and posterior lips of the opening made 
 into the uterus. This has been, on more than one occasion, 
 the source of great help in those cases in which secondary 
 hsemorrhage has set in. In such, if this precaution is not 
 taken, it is often most difficult to get at the stump to 
 examine from whence the bleeding proceeds, as in all these 
 cases the fundus and stump of the uterus recede consider- 
 ably, and it is a great comfort to be able to examine it 
 merely by means of traction of the sutures which pass 
 through the stump, instead of having to grope about through 
 a speculum with Vulsellum forceps. 
 
 In the after-treatment I consider that the parts should be 
 thoroughly syringed out night and morning through di full sized 
 Fergusson speculum. Simple irrigation without the speculum 
 is not sufficient, as often clots may be collected above the 
 opening in the roof of the vagina, and without these are 
 thoroughly removed and the parts cleansed, septic mischief 
 is very likely to follow. 
 
 A few words as to the class of cases in which supra- vaginal 
 amputation of the cervix is applicable, they may be sum- 
 marised by saying that, in my opinion, if a case of carcinoma 
 of the uterus, in which the disease is limited to the vaginal 
 portion of the viscus, and the fundus to all appearance being 
 
30 
 
 free, the uterus movable, and the vaginal walls not impli- 
 cated, such a case is suitable for supra-vaginal amputation, 
 and good results may be anticipated ; and by this operation 
 I mean not only amputation through the neck of the uterus, 
 but a good sized conical piece being removed from body of 
 the viscus, extending, if necessary, to the fundus, and cer- 
 tainly well above the internal os. 
 
 Allow me here to say a few words as to the immediate 
 risks of the high operation. They may be summed up as 
 being limited to haemorrhage and sepsis. With respect to 
 haemorrhage, I have seen cases in which very smart bleeding 
 has occurred during the performance of the operation, this 
 can usually be readily controlled by passing a ligature round 
 the uterine arteries, or by the free application of the cautery. 
 In some cases secondary haemorrhage has caused trouble, 
 but in such the bleeding can invariably be arrested by 
 plugging the vagina. 
 
 From the second danger, sepsis, I have lost one patient, 
 from pelvic cellulitis, the result, no doubt, of sepsis. To 
 avoid this, care must be taken to plug the cavity created 
 by the removal of the diseased cervix with iodoform gauze, 
 and not remove it for the space of three or four days, unless 
 the temperature warns you to remove it earher. The vagina 
 should be kept constantly syringed out through a full-sized 
 Fergusson's speculum twice or three times a day with some 
 antiseptic solution. 
 
 In discussing the method of performing supra-vaginal 
 amputation there are two or three plans advocated by 
 different surgeons who practise this operation, some advo- 
 cating the use of the galvano-cautery, while others prefer 
 the knife or scissors. 
 
 Dr. Baker^ reports that in two series of cases, in the first, 
 covering a period of five years, ending 1882, he had twelve 
 cases of cancer of the uterus by the high operation, and in 
 the seven subsequent years he had operated on sixteen cases 
 by the same operation. Of the first series, 50 per cent, 
 remained well at the end of twelve years. In one case he 
 had to re-open the cervix for the escape of retained 
 menstrual blood. In the second series, operated on from 
 1882 to 1889, in all sixteen cases, he had no death from the 
 
 1 Americal Joiirnal of Obstetrics, vol. xxvi. p. 1224. 
 
3T 
 
 operation, and in ten cases no recurrence of the disease. 
 One case was well at the end of seven years, three at the 
 end of six years, three at the end of three years, and one at 
 end of two years. 
 
 Fifty-three per cent, were well at the time of his reading 
 the paper, the remainder had died of recurrent disease. 
 These operations were done by the removal of the diseased 
 tissue with scissors or the scalpel, the cautery being applied 
 to the raw surface. 
 
 Dr. Reamy,^ of Cincinnati, in reporting a number of cases, 
 also strongly advises the use of scissors or scalpel. He 
 was in the habit of closing the wound in the vagina with 
 sutures and so obtaining primary union. In our own 
 country. Dr. John Williams 3 and myself also strongly 
 advocated the removing of a conical piece of the uterus with 
 scissors beyond the cancerous tissue. 
 
 Dr. John Byrne^ prefers the use of the galvano-cautery. 
 He says " there are only two surgical measures worthy of 
 mention to choose between at the present day, these are 
 first the high amputation or excision as the case may be, by 
 galvano-cautery, not only of all diseased parts, but as much 
 more and beyond the supposed danger-line as can be safely 
 taken away, the removal to be followed by a thorough 
 dry-roasting of all exposed surfaces, or, secondly, vaginal 
 hysterectomy with the more attractive surgical clamour and 
 ghastly records of lives shortened and often sacrificed on the 
 altar of what, now-a-days, is called progressive gynaecology." 
 
 Dr. Byrne's statistics are most brilliant. In nearly 400 
 cases he has not had a single death due to operation ! In 
 forty out of sixty-three of cancer of the portio vaginalis, 
 twenty-three having strayed away, periods of exemption from 
 the disease are reported, ranging two to twenty-two years, 
 being an average for each case over nine years. Of eighty- 
 one cases, involving the entire cervix, thirty-one were lost 
 sight of, ten relapsed within two years, five had no re- 
 currence for two years, two for eleven years, one for thirteen 
 years, and one for seventeen years ; so of the fifty cases of 
 this class, whose histories could be followed up, there was an 
 average period of exemption for each of nearly six years. 
 
 2 Gynaecological Trans. Amer., vol. xiii. 
 ^Harveian Lecture, Lancet, vol. i., 1887, 
 '^Brooklyn Med. Journal, vol. vi. p. 741. 
 
32 
 
 In this county, Dr. Lewers^ reported, at the Royal Medical 
 Chirurgical Society, the result of nineteen cases on which he 
 had operated by scissors and the cautery with no deaths ; six 
 of these had been operated on over two years, and were 
 reported as being free from recurrence. 
 
 Gusserow gives the mortality after supra-vaginal ampu- 
 tation at 9.07 per cent, when the knife is used, and 7.75 
 after galvano-cautery. This would appear from the above 
 remarks to be far above what may be expected, and if 
 suitable cases are selected I am sure the mortality will not 
 exceed 4 per cent. 
 
 It will be seen then that supra-vaginal amputation for 
 uterine cancer in suitable cases is an eminently satisfactory 
 operation. 
 
 VAGINAL HYSTERECTOMY. 
 
 We will now proceed to consider the class of cases which 
 are suitable for total extirpation. 
 
 Dr. Martin, of Berlin, says " I recommend the vaginal 
 extirpation of the uterus as the operation, as the means 
 which we ought to apply in cases of cancerous diseases of the 
 uterus as long as the disease is limited to the organ itself." 
 
 Dr. Skeen, Brooklyn^, speaking of vaginal hysterectomy, 
 says " the operation in my opinion is indicated when the 
 disease is near to or after the menopause. When it begins 
 in the endometrium, more especially in the body of the 
 uterus. . . . When the diagnosis being made and the 
 vaginal wall and fallopian tubes are not involved, and 
 before necrosis has began in any part of the abnormal 
 tissue." 
 
 Now with regard to the immediate recovery, it has been 
 well pointed out by Dr. W. A. Duncan there would be 
 great risk in accepting statistics, of getting the mortality 
 inherent to the operators and not the operation, and I 
 think the rule laid down by Mr. Lawson Tait seems 
 reasonable ; it consists in only dealing with results 
 obtained in the practice of those surgeons whose ability 
 and experience are affirmed. 
 
 If the surgeon is at all doubtful as to the limits of the 
 disease, i.e., if the disease having commenced in the cervix 
 
 5 Royal Med. Chir. Trans., vol. Ixxvi. p. loi. 
 ^ Med. P.ecord, New York, vol. iv. p. 29, 1891. 
 
33 
 
 or external os, and he is uncertain as to how far it has 
 extended into the body of the uterus. Total extirpation 
 should be practised, for as the results of my cases show, 
 and which is confirmed by Leopold, Kaltenbach, D. de Ott, 
 Pean, Pozzi, Japp Sinclair, Lewers, and others, the 
 immediate mortality in suitable cases from vaginal hys- 
 terectomy in experienced hands may be looked upon at 
 from 5 to 8 per cent. 
 
 I think then we may adopt the rule : That when the 
 disease has extended beyond the cervical canal, or has commenced 
 in the fundus of the uterus, and the uterus itself is freely 
 movable and readily drawn down to the vulva, that such cases 
 are suitable for operation. But if the disease has extended to 
 the broad ligaments, or if the vaginal wall is seriously impli- 
 cated, or if we can feel any enlargement of the lumbar or sacral 
 glands and the uterus is fixed, then it will be wise to either 
 leave matters alone or adopt some palliative measures, to which 
 I have alluded. 
 
 With regard to the question of recurrence after operation, 
 it is difficult to lay down any rule, as it is impossible to 
 estimate how far the lymphatics may be involved or the 
 disease extended into the loose areolar tissues around the 
 neck of the uterus. But we may be guided to a large extent 
 by the nature of the malignant growths which exist, and for 
 this purpose I think we might do much if we, as a preliminary 
 measure, satisfied ourselves on this point by obtaining a 
 small scraping and having it examined microscopically. I 
 think it will be found that some of these rapidly growing 
 medullary carcinomata or small round-celled sarcomata recur 
 very much more quickly and certainly than adenoid carci- 
 noma or epithehoma. With regard to the length of time 
 patients live after the operation of supra-vaginal amputation 
 of the cervix and total extirpation of the organs, there are no 
 statistics to guide us^ but judging from the statistics recorded 
 by Hofmeier, which my own experience thoroughly agrees 
 with, of the comparative length of time that patients 
 remained free from recurrence after total extirpation and 
 supra-vaginal amputation of the cervix it would appear 
 that such is the case.. From these statistics embracing 
 entire operations and partial ones from the practice of 
 Schroeder, it will be seen that the percentage of cases in 
 which patients were free from the disease at the end of one 
 
 c 
 
34 
 
 year was in favour of total extirpation of the organ, yet each 
 year after this the advantage gradually decreased, until at 
 the end of the fourth year not one of the cases of total 
 extirpation were free from recurrence, while 41.3 per cent. 
 of those cases in which partial removal of the organ had 
 been practised were well. 
 
 Now there appears to be two ways of explaining these 
 statistics, one is that in those cases in which partial removal 
 was practised, the disease was recognised and removed 
 before the lymphatics became affected. The other explana- 
 tion is that in the cases of partial removal, the disease was 
 either epithelioma or adenoid carcinoma, while in many of 
 those in which the whole organ was removed the disease was 
 either sarcoma or medullary carcinoma. 
 
 I think it will be found that a large number of cases of 
 malignant disease of the uterus are sarcomatous, much 
 more so than is generally imagined. Of those which I have 
 operated on two-thirds were pronounced by the pathologist 
 to be suffering from sarcoma. 
 
 In one case of sarcoma the disease returned at once, and 
 I shall watch with interest to see how long the other cases 
 remain free from the disease. I consider this a very 
 important point, and if it can be proved that these rapidly 
 increasing growths do return quickly it is a question if the 
 case so affected should be subjected to operative interference 
 at all, or at any rate only when seen quite early. This point 
 is one well worthy of study. 
 
 METHOD OF PERFORMING OPERATION. 
 
 The next question we have to discuss is, what is the best 
 method of performing the operation ? 
 
 The patient should have, for some days previously to 
 operation, the vagina thoroughly douched out with either 
 perchloride of mercury solution or strong carbolic acid 
 solution 1-40. On the day previous to the operation a dose 
 of castor oil or a good dose of salts in a tumblerful of hot 
 water should be given early in the morning, and on the 
 morning of operation a large enema should be administered. 
 
 Early on the morning of operation some good strong beef 
 tea should be given and beef tea enema about four hours 
 previously to the operation. And just before the patient is 
 
35 
 
 placed on the table an enema of three ounces of beef tea 
 and one of brandy should be administered. 
 
 The patient should be placed on the table in the lithotomy 
 position being fixed by means of a Clover's crutch. The 
 vagina is then to be well washed out with a strong solution 
 of carbolic acid 1-40. A Sim's speculum introduced into 
 the vagina and the edges of the diseased uterus seized with 
 . vulsellum forceps by means of which the uterus should be 
 drawn well down towards the vulva. 
 
 A bladder sound must next be introduced into the bladder 
 to define its relation to the cervix or uterus. This having 
 been ascertained, the mucous membrane of the vagina is to 
 be divided as far away from the diseased part as possible 
 and the cellular tissues around the cervix be detached just 
 as in the operation for supra-vaginal amputation. 
 
 The bladder being pushed well forward with the finger or 
 blunt end of scissors ; the peritoneum will then be recognised 
 in the front of the uterus, this must be divided freely. The 
 next step is to open the peritoneum in Douglas's pouch. 
 This being done, by placing the forefinger of the left hand 
 into the peritoneal cavity in front and the thumb behind, it 
 is easy to grasp the broad ligament. The uterus being now 
 drawn well down and a few snicks made with the scissors on 
 each side the uterine arteries will be readily recognised. I 
 then pass my long needle smoothly up upon the uterus in 
 front, then the point being felt just above the uterine arteries 
 is depressed and forced through the broad ligament the 
 point being brought into the vagina through the posterior 
 opening in Douglas's pouch. This is threaded with No. 4 
 Chinese silk and withdrawn, the ligature is tied tightly about 
 an eighth of an inch from the uterus. A pair of pressure 
 forceps applied between the ligature and uterus and the 
 parts divided with scissors. The same manoeuvre is carried 
 out on the other side. The uterus will now be found to be 
 quite freely movable and it is an easy matter in those cases 
 in which the uterus is not enlarged and the vagina is fairly 
 large to either ante-vert or retro-vert the uterus. All the 
 vulsella forceps that have been on are to be removed. The 
 uterus being turned over so as for the fundus to be in the 
 vagina the ovaries and tubes are readily brought into view 
 and the ovarian arteries ligatured and the broad ligament 
 divided on each side. 
 
36 
 
 The uterus then is removed and all bleeding being 
 arrested the cavity of the abdomen is flushed out with 
 sterilized water, or a weak solution of boric acid. The 
 anterior and posterior flaps of the peritoneum are seized 
 with forceps and drawn well down, a glass tube inserted and 
 the vagina packed with iodoform gauze. Finally, a winged 
 catheter is placed into the bladder, and a morphia and 
 belladonna suppository into the rectum, and the patient 
 returned to bed with hot water bottles around her. If all 
 goes well the dressing should not be removed until the third 
 or fourth day. 
 
 In those cases in which the uterus is very much enlarged 
 it may be necessary, indeed, it is more easy, to perform the 
 operation by, in the first place, freeing the cervix and 
 ligaturing the uterus, per vaginam, and then opening the 
 abdomen in the middle line and ligaturing and dividing the 
 broad ligaments through the abdominal opening and 
 removing the uterus through the opening. 
 
 In some cases of elderly unmarried women it will be 
 necessary to divide the perineum to obtain room for 
 manipulation. This, however, should never be done if it 
 can be avoided, as there is always the risk of tearing 
 into the rectum. In connection with the operation several 
 important questions of detail arose. 
 
 First, should the haemorrhage be controlled with clamp 
 and forceps, or should the surgeon only adopt the use of 
 the ligature ? In the Archives Generales de Medecine, 
 G. Richellet ("Annals of Surgery," vol. xvii, part 9, p. 334) 
 has furnished an article based upon his experience acquired 
 in 225 operations of vaginal hysterectomy, in which he had 
 eleven deaths. Operations, as the writer says, "were made 
 under the most varied and dangerous conditions, having 
 never declined to operate when there seemed a chance of 
 recovery for the patient." This operator appears to use the 
 clamp exclusively for arresting haemorrhage. Pean and 
 others also adopt the use of the clamp. My own experience 
 is that in all cases where a ligature can be applied it should 
 be. It is all very well to say that the use of the clamp saves 
 time, and acts as drainage, so they may, but, as I have 
 shewn in another place, the results after the use of the 
 clamp are not so good, and this can, I think, be explained 
 by the fact that to the patients the retention of a large 
 
37 
 
 number of forceps for thirty-six or forty-eight hours is 
 painful, the risk of haemorrhage on their removal, although 
 not great, at any rate exists ; and lastly the necrosed portion 
 of tissues which have been compressed by the clamp remain 
 in the wound after removal, and may act as a fruitful source 
 of septicsemia. Moreover, with these forceps in the vagina 
 the peritoneal wound is kept open, and the risk of intestinal 
 adhesions or peritonitis is considerably increased. Further, 
 one or both ureters might be compressed by the forceps, as 
 has to be done on occasions by the most experienced 
 surgeons. I have had some forceps made for me by Messrs. 
 Weiss, which in certain cases of short, thick, broad ligaments 
 can be readily, and I think advantageously, applied. 
 
 Now, there is a considerable difficulty in many cases in 
 applying the ligature. To get over this I have had these 
 needles made, which, you will observe, are fashioned in such 
 a manner that there is a long arm from the bend in the 
 needle to its point; it is also furnished with a large eye so 
 as readily to be threaded. These needles can be easily 
 slipped over the uterus and made to pierce the broad 
 ligament at the spot desired, the point being brought out 
 into the vagina and threaded. By this means I find it very 
 much easier to ligature the uterine arteries and lower part of 
 the broad ligature than by any other needle I have seen. 
 This being accomplished in those cases when the uterus is 
 not large it can be readily either retro- or ante-verted, and 
 the ovaries, arteries, and remainder of the broad ligament 
 ligatured. 
 
38 
 
 Should the Ovaries and Tubes be removed} In the 
 majority of cases in women who have passed the cHmacteric 
 I should certainly say no, but in younger women if the 
 ovaries present into the wound I do not think the risk to 
 the patient is increased by their removal. I have but 
 little doubt, however, that they become atrophied in a very 
 short while after the uterus is removed, and cause no 
 trouble by being retained. Dr. W. Duncan has, however, 
 reported a case in which there were three very sharp attacks 
 of pain, that correspond exactly with the menstrual periods, 
 showing indubitably ovulations with circumscribed peri- 
 tonitis. 
 
 I have now a patient from whom I removed this large 
 sarcomatous uterus who suffers periodically in the same 
 way ; the mammse also becoming enlarged and painful and 
 she also suffers from severe headaches at these times. 
 
 Drainage. — The question of drainage as in abdominal 
 operation is one which has not been as yet settled. In the 
 cases I have operated on I used drainage in some and not 
 in others. In one case that died I am very strongly of 
 opinion that I lost her because I did not drain. The rule 
 that I have adopted is that in those cases in which the 
 diseased uterus is removed without difficulty, I merely pack 
 the vagina with idoform gauze, and do not introduce a 
 drainage tube, but those in which there is much tearing or 
 difficulty in getting the uterus out I consider should always 
 be drained by the introduction of a glass drainage tube, 
 which can be emptied every six hours, as may be necessary. 
 I prefer a glass drainage to rubber tubes, for the reason that 
 they do not collapse when the vagina is packed, and being 
 firm any oozing is suppressed by means of the pressure that 
 is exercised. The tube can be removed at the end of 
 twenty-four or forty-eight hours if there is no sero- 
 sanguineous fluid. A narrow slip of gauze should be intro- 
 duced into the tube. 
 
 The Treatment of the Peritoneal Flaps. — The next point 
 of importance, and this is one to which too much attention 
 cannot be paid, is the treatment of the peritoneal flaps. It 
 has been suggested and practised by some surgeons, 
 especially on the Continent, to unite these flaps by a 
 continuous suture ; others leave them alone. I have found 
 by experience that the first of these two lines of practice i§ 
 
39 
 
 unnecessary, and the other is fraught with great danger. 
 Now, if you will examine the position and condition of 
 these flaps after the uterus is removed, you will find that in- 
 variably the peritoneum is curled up and doubled upon 
 itself thus, so that if they are left alone the whole raw surface 
 has a tendency to drain into the peritoneal cavity, more- 
 over, should there be any oozing into the peritoneum this 
 very doubling up of the flaps would be apt to prevent its 
 discharge through the vagina; there is great danger also of a 
 knuckle of intestine becoming adherent to the wound, and 
 trouble created by this. It is the want of attention to this 
 detail that has led to disaster in many cases. To overcome 
 this I invariably catch the edges of the flaps with long 
 curved forceps, fixing two pairs of forceps on to each flap, I 
 then draw these firmly down, keeping the ends of the for- 
 ceps approximated, and then pack strips of iodoform gauze 
 firmly on each side of the flaps, so as to cause the peritoneal 
 surface to be brought into accurate opposition. By adopt- 
 ing this practice there is no necessity to unite the flaps by 
 suturing. Should the drainage tube be inserted I pull the 
 flap well down just the same. 
 
 Flushing the Peritoneum. — Before finally packing the 
 vagina, it is of the greatest importance that the peritoneum 
 should be thoroughly well flushed out with sterilised water, 
 as often small clots of blood or debris are left in the cavity. 
 
 Packing the Vagina. — Finally the vagina is packed firmly 
 with strips of iodoform gauze, iodoform being puffed into 
 the canal as each strip is inserted. A winged soft rubber 
 catheter should be inserted into the vagina, and the patient 
 returned to bed. 
 
 The immediate mortality after total extirpation of the 
 uterus by Continental surgeons is reported to have decreased 
 to about 10-5 per cent, as a general average, while certain 
 operators claim to have succeeded in reaching a death rate 
 as low as 3 or 4 per cent. In comparing the comparative 
 merits of such operations as supra-vaginal amputation of the 
 cervix uteri for cancer and total extirpation of the uterus 
 for the same disease, not only must the immediate mortality 
 after the operation be taken into consideration, but also the 
 state the patient is left in. 
 
 Now, in dealing with this operation we must compare 
 only those cases in which the operation has been performed 
 
40 
 
 for cancer, we must have no watering down of statistics by 
 the addition of operations which have been done for minor 
 ailments ; we must also of necessity confine our remarks to 
 those cases in which the disease is limited to the vaginal 
 portion of the uterus, as it is obvious if the body of the 
 uterus is involved the high operation is not practicable, and 
 the only operation that can be practised with any hope of 
 relief must be that for total extirpation of the organ. 
 
 Now, for a few minutes, let us examine into the dangers 
 which may follow total extirpation of the uterus ; they are 
 by no means either few or trivial. 
 
 Intestinal Obstructmi has been met with on several 
 occasions after vaginal hysterectomy, the result of 
 adhesion of a loop of intestine to the edges of the wound 
 caused by the removal of the uterus. In the American 
 Journal of Obstetrics, vol. xxiii.. Dr. Coe has reported two 
 cases which occurred in his own practice, and eight which 
 he collected from other sources. In all of these 
 laparotomy was performed for the relief of the obstruction 
 with fatal results. The pathological conditions and 
 clinical symptoms were almost identical in these cases ; in 
 each case there was an adhesion of one or more coils of 
 intestine to the edges of the vaginal wound, with disten- 
 sion and bending of the gut above the point of adhesion, 
 thus obstructing ihe lumen. Although there was intense 
 congestion of the serous coverings of the intestine, in 
 neither instance was general peritonitis found at the 
 operation. In all but one case death seemed to be due 
 primarily to exhaustion, or in those cases in which 
 laparotomy was performed, to the shock of the operation. 
 The symptoms continued indefinite until the fourth day, 
 and the classic symptoms of intestinal obstruction, 
 especially fascal vomiting appeared when it was too late 
 to profit by them. 
 
 A similar case occurred to me only the other day, a com- 
 paratively easy case for operation. The uterus which I 
 have here was removed, there was very little haemorrhage, 
 but the ometum came down into the vagina. This was 
 pushed back. On the second day the patient had vomiting, 
 but no tympanitis. The symptoms increased, and on the 
 fifth day became urgent. I opened the abdomen, and 
 found the omentum strongly adherent to the wound in the 
 vagina, binding down a loop of intestine. I released this, 
 
4T 
 
 and the next day the bowels were opened freely, but the 
 patient succumbed, and died of exhaustion. 
 
 Dr. Cullingworth, in giving the subsequent history of 
 four cases of vaginal hysterectomy, says two enjoyed 
 perfect health until within a few days of their death. In 
 each of these cases death resulted from intestinal obstruc- 
 tion, the cause of which in one case remains unknown ; 
 in the other it was due to pelvic adhesions. 
 
 Professor Reichal,' in an article on ileus after vaginal 
 hysterectomy reports three cases of intestinal obstruction. 
 
 Other cases have been reported by Drs. Bokelmaan,® 
 Leopold,® and Lundau,^" death resulting in each case. 
 Later cases have been reported by Dr. Coe." This accident 
 of intestinal adhesion to the raw surfaces seems to.be more 
 frequent when forceps are used to control haemorrhage 
 than when the ligature is used. 
 
 URETERS. 
 
 A second source of danger in this operation is met with 
 chiefly in those cases in which the disease has extended 
 somewhat laterally, from the risk of either dividing the 
 ureter, or including them in the ligature or forceps applied 
 to the broad ligament to arrest haemorrhage. Any surgeon 
 who has performed vaginal hysterectomy frequently is well 
 aware of this danger, and there are few who could not 
 recall cases in which this accident has happened to them ; 
 there are several such cases recorded. 
 
 Vesico-vaginal or recto-vaginal fistula are by no means 
 so rare as might be supposed after total extirpation of the 
 uterus ; there are several cases on record, and these could 
 be, I think, considerably increased if all such accidents 
 were reported. Vesico-vaginal fistulas are especially liable 
 to occur in those cases in which the disease is somewhat 
 extensive and the pelvis contracted, necessitating a good 
 deal of force to enucleate the uterus. This catastrophe 
 does not sometimes declare itself for some days after the 
 operation, but when the slough becomes detached the 
 surgeon, to his horror, on visiting his patient finds urine 
 
 ^ "Zeitschrift fiir Geb. u. Gyn." Band xv., Heft i. 
 
 " "Archives fiir Gyn." Band xxv., Heft i. 
 
 s Ibid. Band xxx., Heft 3. 
 
 "^^ Berlin Klin Wochenschrift, 1888, No, 10. 
 
 11 Am. Journal of Obstet., vol. xxxiii., p. 469. 
 
42 
 
 trickling out of the vagina. Often the opening is so high 
 up that it is difficult to locate the exact seat of the urinary 
 fistula, and I need hardly point out that in these cases the 
 hopes of closing the fistula must be very small. 
 
 Another source of danger is peritonitis, especially in 
 those cases where the parts are of necessity much dragged 
 and torn. 
 
 Sepsis again is answerable for many of the deaths. And 
 lastly haemorrhage often is severe and alarming. 
 
 RESULTS. 
 
 In referring to the statistics of the result of total extirpa- 
 tion of the uterus, Dr. Paul F. Munde and Burke, in a most 
 instructive paper reported in the Annual of Universal 
 Medical Science, vol. II, 1891, have reported 492 cases in 
 which the operation was performed by several different 
 operators, the immediate mortality averaging io'5 on all 
 cases. 
 
 The comparison of the operation when performed by 
 different methods is very instructive, thus the mortality 
 when ligature alone was adopted is as low as 6"6 per cent., 
 when the ligature and clamp were used it rose to 11 '5 per 
 cent., and when the clamp alone was the method employed 
 for controlling the blood vessels the deaths still further 
 increased to i6"6 per cent. This large difference in the 
 death-rate seems to be accounted for by the cases in which 
 the ligature alone was used being those in which the 
 disease was limited, and the uterus readily drawn down 
 out of the vulva. In such cases the high operation would 
 probably have been efficacious. So that it would appear 
 that the higher rates of mortality might have been 
 accounted for more by the extent of the disease than by 
 the method adopted of securing the vessels. 
 
 In a recent discussion'* upon the relative merits of 
 vaginal hysterectomy and supra-vaginal amputation for 
 cancer of the uterus, which took place at the Obstetrical 
 Society, opinions seemed to differ materially, but the 
 weight of the argument appeared rather to tend in favour 
 of the lesser operation. Dr. William Duncan, alluding to 
 the mortality after total extirpation, referred to the series 
 of cases leported by Professor Japp Sinclair, and observed 
 
 1^ Lancet, 1893, ^'°''* ^^ P' "• 
 
43 
 
 that his mortality was certainly as small as that of supra- 
 vaginal amputation. 
 
 Drs. Terrier and Hartman^^ give details of a series of 
 thirty-four vaginal hysterectomies with eight deaths. One 
 from haemorrhage on the seventh day, two died from shock 
 and hemoirhage in forty- eight hours, two died from shock 
 on the third day, two succumbed to peritonitis. In one 
 case a pair of forceps had pinched a loop of intestine, 
 causing perforation, and in one case the uterus was very 
 adherent, and in the last case death resulted from phlebitis 
 fourteen days after operation. In considering the ultimate 
 results these physicians report two cases as well without 
 any recurrence after six years, four months ; one after 
 four and a half years ; in the others relapse occurred, in 
 eight cases, at periods between one month and two years ; 
 one in two and a half years ; and three are free from 
 disease at time of report, at periods from eight months to 
 three years after operation. Three cases were incomplete, 
 in one necessitating the opening of the cul-de-sac and 
 bladder, and two have suspicious nodules at the side of the 
 vagina. 
 
 The conclusions arrived at are that relapse is frequent, 
 about 70 per cent., and often rapid, but may not manifest 
 itself by signs noticeable to the patient until a considerable 
 time ; 30 per cent, of those who survive seem to be com- 
 pletely cured. 
 
 Post (the American Journal of Obstetrics, November, 
 1887), in 700 cases of vaginal hysterectomy he has 
 collected, asserts that the mortality after the operation is 
 24 per cent. Dr. Florian Krug,^* New York, gives us his 
 personal experience with vaginal hysterectomy. He is 
 strongly in favour of total extirpation in suitable cases, 
 and reports fifteen on whom he had performed the opera- 
 tion during three years. Two of these were done for 
 non-malignant disease of the uterus, and one for a doubtful 
 case of malignancy, thus reducing the number to twelve 
 cases. One of these died from the operation, and one 
 had recurrence in five months^after the operation. All the 
 others are reported as having had no recurrence and being 
 in perfect health. Nine of these cases had, however, only 
 
 13 Revu de Chirurgie, April, 1892. 
 
 1* American Journal of Obstetrics, vol. xxiv, p. 796. 
 
44 
 
 been operated on from three to sixteen months before the 
 reading of the paper: too short a time to give any reliable 
 information as to the recurrence. 
 
 From the few cases in which Dr. Krug has operated it is 
 evident, as he points out, that he only operates on those 
 cases in which he is quite sure he can remove the whole of 
 the diseased tissue ; he says wherever the removal of all 
 diseased tissue is impossible, vaginal hysterectomy is not 
 indicated ; and if recurrence takes place soon after it has 
 been performed, it only goes to show that cancerous foci 
 have been left behind. He then goes on to describe his 
 method of operating vi^hich is based upon the importance of 
 absolute asepsis and cleanliness. To obtain this he invari- 
 ably subjects his patients to examination under narcosis and 
 at the same time thoroughly curettes the uterine cavity in 
 corporeal cancer, or removes the soft sloughy tissue with the 
 sharp spoon or scissors in cases of cervical epithelioma. 
 The cautery is then freely applied, and for about a week or 
 so vaginal douches are given, sometimes tannin and iodo- 
 form powder is applied, until a clean surface is obtained. 
 Directly before the secondary operation he thoroughly scrubs 
 the vagina with mollin containing lo per cent, of creolin by 
 means of a brush. He then proceeds to remove the uterus. 
 He further lays great stress on the treatment of the stump 
 and prefers the ligature to the clamp. The stump is to be 
 inverted towards the vagina and the peritoneal wound care- 
 fully packed with iodoform gauze which may be safely left 
 in situ for eight days. 
 
 I have now performed vaginal hysterectomy upon twenty- 
 seven cases of uterine cancer, only two of which have 
 succumbed to the operation, thus giving a mortality of less 
 than 8 per cent. ; one of these cases died from peritonitis, 
 the other from intestinal obstruction caused by a piece of 
 omentum becoming adherent to the roof of the vagina and 
 constricting a loop of intestine. I opened this patient's 
 abdomen on the sixth day and detached the omentum and 
 released the constriction, the patient, however, died. 
 
 Recurrence in the site of disease within six months has 
 taken place in three cases. 
 
 The ureters were divided in three cases, and in one old 
 maiden lady in which I had to divide the perineum, recto- 
 vaginal fistulte resulted. 
 
45 
 
 I have now placed as clearly as the time at my disposal 
 will permit the result of these two operations. By com- 
 paring these results I hope to come to some conclusion as 
 to which is the operation to be recommended in future. In 
 doing this I propose to compare (i) the dangers coincident 
 to the two operations ; (2) the immediate mortality after the 
 operation ; (3) the periods of freedom from recurrence, and 
 (4) general results. 
 
 I. Amongst the dangers, as I have pointed out, in vaginal 
 hysterectomy, quite a number of patients have succumbed 
 to intestinal obstruction due to some portion of the intestine 
 becoming adherent to the edges of the vaginal wound. Dr. 
 Krug nearly lost one patient by this cause and it was only 
 by his timely intervention in examining the vaginal wound 
 that he found a knuckle of intestine protruding through the 
 wound. He broke down the adhesions with his finger, 
 pushed the intestine back and introduced a plug of iodoform 
 gauze and saved his patient. Should symptoms of intes- 
 tinal obstruction appear, then, after this operation, no time 
 should be lost in endeavouring to remove the cause. 
 
 This danger can never be feared after supra-vaginal ampu- 
 tation as the only portion of the peritoneum which is at all 
 likely to be opened is Douglas's pouch, the peritoneal edges 
 of which become glued together and the opening is securely 
 closed within a few hours. The danger of hgaturing or 
 dividing the ureters is a very serious one in the operation of 
 total extirpation, as, should the disease extend laterally or 
 the tissues be thickened by inflammatory mischief, it is 
 impossible to recognise the different structures which present 
 themselves, and it is obvious that in passing a needle through 
 these tissues or in applying pressure forceps the ureter may 
 very easily be included. This can readily be understood 
 when the intimate relations of the ureter and uterine artery 
 are remembered. This is a strong argument against per- 
 forming vaginal hysterectomy when the disease is found to 
 extend laterally, or presumably encroaches on the broad 
 ligaments. In cases of supra-vaginal amputation this danger 
 can never present itself. Vesico-vaginal fistulse are by no 
 means uncommon after vaginal hysterectomy, especially 
 when the disease implicates the anterior portion of the neck 
 of the uterus ; in such cases inflammatory thickening takes 
 place in the cellular tissue between the bladder and uterus. 
 
46 
 
 and it can be readily understood how in such cases the 
 bladder may be torn. In cases suitable for the high operation 
 this danger can rarely if ever exist. Peritonitis should 
 rarely be anticipated after either operation if the vagina has 
 been rendered thoroughly aseptic, either after the one oper- 
 ation or the other. This misfortune seems to be much more 
 likely to follow vaginal hysterectomy when the broad 
 ligaments are clamped than when the ligature is used. 
 Haemorrhage both primary and secondary is liable to cause 
 trouble after both operations, perhaps even more so after 
 the high operation, as by the traction which is exercised 
 during the removal of the diseased tissues the vessels become 
 temporarily closed and at the time no bleeding points present 
 themselves. When, however, the remaining portion of the 
 uterus is returned and the pressure relieved, bleeding 
 may take place. This accident no doubt would be less 
 likely to follow if the cervix were removed by the galvano- 
 cautery. 
 
 2. The immediate mortality after operation can only be 
 obtained from the statistics which have been published. Dr. 
 Byrne, who has been at much trouble to do this, has 
 collected 1,273 cases of vaginal hysterectomy, which have 
 been reported, and has divided them into different classes 
 according to locality, thus : 
 
 Locality. Operators. Operations. Deaths. Per Cent. 
 
 Continental 
 
 .. 14 
 
 944 
 
 137 
 
 14-5 
 
 British 
 
 .. 8 
 
 74 
 
 15 
 
 20.0 
 
 United States 
 
 .. 16 
 
 255 
 
 34 
 
 13.0 
 
 Total 
 
 38 
 
 1273 
 
 186 
 
 14.6 
 
 We may then safely place the immediate mortality after 
 total extirpation as hitherto practised at about 10 percent. 
 Now if we compare these figures with the results after 
 supra-vaginal amputation, we shall find that the result is 
 very much in favour of the latter operation. Dr. Byrne 
 tells us that in 400 cases in which he had performed the 
 high operation by galvano-cautery he had no deaths, and 
 Dr. Lewers, in 19 cases by the same method, likewise 
 records no death. Dr. Baker, in a series of z8 high opera- 
 tions, had also no death. In 24 cases which I have 
 reported 1 had only one death. The immediate risk, then, 
 from this operation appears to be practically nil. 
 
47 
 
 3- The length of lime that the patient remains free from 
 recurrence would appear to depend entirely upon degree. 
 This is well exemplified, as by Drs. Terrier, Hartman, and 
 Reed. According to the observations of these physicians, 
 cases in which the disease has been recognised quite early, 
 are practically cured by either operation ; but, seeing the 
 dangers which beset the major operation, and which are 
 absent in the minor, surely it would be wiser to practise 
 the latter. 
 
 4. It only remains for me to make a few remarks as to 
 the choice of cases, and in doing this I shall perhaps not 
 be far wrong in recommending surgeons to operate only 
 upon those cases which are seen early, and in which the 
 disease is limited to the vaginal portion of the uterus or to 
 the cervix and cervical canal, the uterus being freely 
 movable, and the disease not extending laterally along 
 the broad ligaments or the cellular tissue between the 
 peritoneum and the fornix. In such cases, no doubt, the 
 results would be almost as good by adopting the one 
 operation as the other, so far as the immediate mortality 
 and chances of recurrence of the disease are concerned ; 
 but, taking into consideration the dangers and complica- 
 tion which may follow the major operation of removing 
 the whole organ and destroying the roof of the vagina, I 
 cannot but think that supra-vaginal amputation of the 
 disease will not only maintain its high position, but that 
 many of those surgeons who are at present opposed to it 
 will gradually become converted, and will adopt the total 
 extirpation of the entire organ only in those cases in which 
 the disease is situated in or has extended to the body of 
 the uterus. 
 
 Gentlemen, I trust I have not wearied you, but in 
 examining into this subject I have endeavoured to the best 
 of my ability to place before you fairly and dispassionately 
 the results obtained by surgeons of all shades of opinion, 
 trusting that we may profit by their experience, and in the 
 future be able to bring the results of such experience to 
 so bear upon our practice that the result of the operative 
 treatment of cancer of the uterus may occupy a position 
 in the annals of surgery and gynaecology that may prove a 
 triumph of our art, and a lasting benefit to thousands of 
 poor suffering women who may seek our aid. 
 
APPENDIX OF CASES. 
 
 In illustration of these lectures, it will not be out of place to 
 record short histories of cases on which I have operated for 
 uterine carcinoma. 
 
 First, those cases in which the disease has not progressed 
 so far as to preclude the hope of getting beyond it by supra- 
 vaginal amputation of the os and cervix. 
 
 Secondly, those cases in which the disease has extended 
 up the cervical canal so far as to render the minor opera- 
 tions doubtful, or in which the fundus of the uterus is 
 implicated, and in which total extirpation of the entire 
 organ alone gives any reasonable hope of eradicating the 
 disease. 
 
 Thirdly, those cases in which the disease is so extensive 
 as to preclude the possibility of removing it by any surgical 
 interference, but in which much benefit may be hoped for 
 by the judicious application of caustics. 
 
 THIRTY-NINE CASES OF SUPRA-VAGINAL AMPUTATION OF 
 THE CERVIX UTERI FOR CARCINOMA. 
 
 First, then, I will narrate short histories of thirty-nine 
 cases of supra-vaginal amputation of the os and cervix, with 
 a mortality of 5 per cent. 
 
 Twenty-five of these cases were embodied in a paper read 
 by me before the British Gynaecological Society, Decem- 
 ber 8, 1892.* 
 
 The cases I have selected are those in which I have 
 operated during the years 1889 to 1894. With the excep- 
 tion of a few cases, the specimens have been microscopically 
 examined and pronounced to be carcinoma ; those cases 
 which were of a doubtful character certainly presented macro- 
 scopically all the appearance of malignancy. 
 
 * British Gynacological Journal, vol. viii., p. 353. 
 
 4 
 
5° 
 
 In the year 1889 I operated upoji four cases. 
 
 Case I. — Mrs. B , aetat sixty; large family. Dura- 
 tion of the disease several months. The os was deeply 
 ulcerated and hardened, the cervix thickened and somewhat 
 nodular. Uterus freely movable. Vagina free from disease. 
 On May i, 1889, I performed supra-vaginal amputation of 
 the cervix, at the same time cutting out a large conical 
 piece above the internal os, the apex of the cone extending 
 nearly to the fundus. The patient made an excellent 
 recovery, and had a good sound stump. She kept free 
 from the disease until September, 1891, when recurrence 
 took place, and the patient declined further operative inter- 
 ference. 
 
 Case 2. — Mrs. , setat sixty-one ; married, several 
 
 children. The external os is ulcerated, the ulceration ex- 
 tending into the cervical canal. Bleeds freely ; much in- 
 duration. On July 16, 1889, I performed supra-vaginal 
 amputation of the cervix. The patient made an excellent 
 recovery, and remained free from disease until her death, 
 which took place some two years afterwards from bronchitis. 
 By the courtesy of Dr. McCaskie I was enabled to obtain 
 the uterus, and there was no trace of recurrence. 
 
 Case 3. — Mrs. W , tetat forty- two ; married, four 
 
 children ; duration of the disease some six months. Os 
 presents a ragged, ulcerated surface ; the cervix is hard and 
 thickened. Uterus movable, vagina free. On Septem- 
 ber 22, 1889, I performed supra -vaginal amputation of the 
 OS and cervix, curetting the endometrium, which was left. 
 Patient made an excellent recovery, and is now free from 
 any recurrence. 
 
 Case 4. — Mrs. H , aetat forty-one ; married, two 
 
 children ; duration of disease twelve months. Posterior lip 
 is thickened and rough, deep ulceration extending into 
 cervix; uterus movable, vagina free. Supra- vaginal amputa- 
 tion performed December 2, 1889. There was some free 
 hemorrhage, which was arrested by plugging. Wound 
 healed well, and the patient has had no recurrence until 
 now. Suffered for some year or eighteen months with 
 much pain and distress at the ordinary menstrual periods. 
 
51 
 
 During 1890 I operated on eleven cases. 
 
 Case 5. — Mrs. W , setat fifty-four ; married, two 
 
 children ; duration of disease said to be only five months. 
 Os and cervix indurated and somewhat ulcerated ; uterus 
 enlarged, and only slightly movable. Supra-vaginal amputa- 
 tion performed February 2, 1890. The stump healed 
 slowly, and the patient made a tedious convalescence. 
 There was recurrence of the disease in three months. 
 
 Case 6. — Mrs. H , setat twenty-nine; four children. 
 
 Has had an offensive discharge for six months. The cervix 
 is hard and thickened and fissured ; the os ulcerated, 
 reddened and slightly irregular. Vagina free. Supra- 
 vaginal amputation performed March i, 1890. Patient 
 made a good recovery, and is free from any recurrence. 
 This was a doubtful case of carcinoma, although it had all 
 the general appearance of cancer. 
 
 Case 7. — Mrs. C , aetat fifty-four ; widow, two 
 
 children. Sister died of cancer of the uterus. She had 
 noticed a discharge for eight months. Cervix enlarged and 
 indurated. Vaginal surface not ulcerated. Offensive dis- 
 charge. Uterus movable. Has had a good deal of 
 haemorrhage. March 25, 1890, supra-vaginal amputation 
 performed ; rather severe hccmorrhage. Patient made a 
 good recovery, but had recurrence of the disease in a few 
 months. 
 
 Case 8. — Mrs. S , setat forty-five ; three children ; 
 
 duration ten months. Aunt died of cancer. Cervix en- 
 larged, indurated, and ulcerated. Several isolated nodules 
 on cervix. Uterus movable. April 20, 1890, supra-vaginal 
 amputation. Patient made an excellent recovery, and has 
 had no recurrence. 
 
 Case 9. — Mrs. B , setat thirty-five ; married ; dura- 
 tion eight months. Cauliflower growth from cervix. 
 Uterus movable ; vagina free. Supra-vaginal amputation, 
 April 14, 1890. Patient progressed favourably for the first 
 three days after the operation, when she had a rigour, and 
 temperature rose to 103 "8°, accompanied with vomiting. 
 Some pus was let out, and a drainage-tube inserted. She 
 had several more rigors, accompanied with high tempera- 
 ture, and died. Post-mortem revealed extensive pelvic 
 cellulitis. 
 
52 
 
 Case lo. — Mrs. H , cetat forty-two; married, six 
 
 children ; duration of disease ten months. An irregular 
 ulcerated growth is seen springing from the cervix, more 
 especially from the posterior lip. Uterus mobile ; vagina 
 free. Supra-vaginal amputation on May 20, 1890. In this 
 case the disease extended higher than was anticipated. 
 The endometrium was curetted, and the cavity of the uterus 
 packed with strips of gauze soaked in a saturated solution 
 of chromic acid. There was some sharp hsemorrhage on 
 the slough — the result of the chromic acid — separating. 
 The patient, however, made a very good recovery, but the 
 disease recurred in a few months. 
 
 Case II. — Mrs, R , aetat sixty; two children; dura- 
 tion of disease four months. Father died of cancer. Large 
 cauliflower growth springing from cervix ; bleeds freely when 
 touched ; uterus freely movable. Supra-vaginal amputa- 
 tion, August 9, 1890. Free hsemorrhage; vagina plugged 
 with gauze. Patient made a good recovery. Lost sight of. 
 When last seen, some months after operation, there was no 
 recurrence. 
 
 Case 12. — Mrs. G , ^tat thirty-nine; married, four 
 
 children ; duration of disease twelve months. Cervix 
 ulcerated and ragged ; uterus somewhat fixed ; offensive, 
 blood-stained discharge. On July 26 supra-vaginal ampu- 
 tation performed. There was great difficulty in getting 
 beyond the disease, and although the patient made a fairly 
 good recovery, the disease recurred directly. 
 
 Case 13. — Mrs. P , setat forty-three; married, 
 
 eleven children ; duration of disease nine months. Irregular 
 growth of considerable size springing from cervix. Left side 
 of OS more especially affected. Free hsemorrhage at times. 
 Supra-vaginal amputation, August 12, 1890. Patient made 
 a good recovery, and there was no recurrence when last 
 seen. 
 
 Case 14. — Mrs. O'C , setat fifty-four; one child; 
 
 duration of disease six months. Extensive ulceration of os ; 
 cervix hard and indurated. Uterus movable ; vagina free. 
 Supra-vaginal amputation, November 7, 1890. Sharp 
 hsemorrhage ; forceps left on. Patient made a good re- 
 covery. No signs of recurrence at present time. 
 
 Case 15. — Mrs. R , aetat fifty-seven ; married, one 
 
 child; duration of disease twelve months. Well defined 
 
53 
 
 roughened irregular growth from cervix, accompanied with 
 profuse, very offensive discharge. Uterus freely movable. 
 Vagina free from disease. Supra-vaginal amputation per- 
 formed December 5, 1890. Patient made a good recovery, 
 and has had no recurrence. 
 
 In the year 1891 I performed ten operations. 
 
 Case 16. — Mrs. H , getat fifty-one ; widow; duration 
 
 of disease twelve months. A hard, irregular mass spring- 
 ing from the os. Uterus freely movable; vagina free. 
 Supra-vaginal amputation, January 30, 1891. Made good 
 convalescence. No recurrence hitherto. 
 
 Case 17. — Mrs. N , ffitat forty-five; duration of 
 
 disease eight months. An ulcerating mass protruding from 
 cervix ; uterus freely movable ; vagina not implicated. 
 Supra-vaginal operation February 16, 1891. Patient made 
 a good recovery, and has had no recurrence hitherto. 
 
 Case 18. — Mrs. H , getat forty-seven ; three children ; 
 
 duration of disease six months. Cervix infiltrated with 
 growth ; vagina free ; uterus freely movable. Supra-vaginal 
 amputation March 26, 1892. Stump cicatrized well. No 
 recurrence hitherto. 
 
 Case 1 9. — Mrs. S , setat forty-five ; married ; dura- 
 tion of disease six months. Large cauliflower growth ex- 
 tending halfway down the vagina ; uterus mobile ; slight 
 infiltration of vaginal walls posteriorly. May 17, 189 1, the 
 disease was cut away with scissors, and a deep cone-shaped 
 piece excised from the uterus with scissors. Patient, who 
 was in a weak condition, gradually became weaker, and 
 died on June 3, 1891. Unfit case for this operation. 
 
 Case 20.— Mrs. S , ffitat forty-four ; married, three 
 
 children ; duration of disease seven months. Os uteri 
 deeply ulcerated, and cervix considerably thickened and 
 hard. Supra- vaginal operation, May 29, 1891. Made 
 good recovery. No recurrence hitherto. 
 
 Case 2 1. — Mrs. B , setat forty-five; married, no 
 
 children ; duration of disease twelve months. Large 
 ulcerated mass protruding from cervix, implicating vaginal 
 walls. Disease removed with scissors, July 12, 1891, and a 
 deep conical-shaped piece cut out of the uterus. Patient 
 made a good recovery, but the disease recurred three 
 months later. 
 
54 
 
 Case 2 2. — Mrs. M , setat forty-five ; married, seven 
 
 children ; two miscarriages ; duration of disease ten months. 
 Large, hard ulcerated mass implicating both lips of os. 
 Uterus freely movable; vaginal walls free. Supra-vaginal 
 amputation, August 4, 1891. Patient made a good re- 
 covery, and has had no signs of recurrence. 
 
 Case 23. — Mrs. P , setat fifty-one ; married, five 
 
 children ; duration of disease five months. Deeply ulcer- 
 ated condition of os ; cervix infiltrated and hard ; uterus 
 movable ; vagina free. Supra-vaginal operation, Decem- 
 ber 5, 1 89 1. Patient made a good recovery, and is free 
 from recurrence at present. 
 
 Case 24.- — Mrs. W , cetat forty; eight children and 
 
 two miscarriages ; duration of disease said to be two years. 
 Small eroded surface on posterior lip of os, with great 
 thickening and induration of the cervix. This patient was 
 treated for some time without any improvement. Supra- 
 vaginal amputation, December 18, 1891. The disease was 
 found to extend up the cervical canal, and a large conical 
 piece of the uterus was removed, extending well above the 
 internal os. Patient made an excellent recovery, and is quite 
 free from recurrence at present. 
 
 Case 25. — Mrs.S ,3etat fifty- one; married, six children; 
 
 duration of disease three months. A deeply ulcerated 
 patch on posterior lip of os, the edges of which were 
 irregular and everted ; bleeds readily on examination. 
 Supra-vaginal operation, December 19, 1891. Patient 
 made a good recovery, and at present is free from recur- 
 rence. 
 
 In the year 1892 I operated on six cases. 
 
 Case 26. — E. H , setat fifty-one; widow. Admitted 
 
 January 26, 1892. Has been suffering from an offensive 
 discharge . for some months. Os deeply ulcerated, bleeds 
 readily on examination. Vagina free ; uterus movable ; 
 cervix hard. Supra-vaginal amputation, and large cone- 
 shaped piece removed, on January 30. Patient discharged 
 February 23. Wound quite healed ; no recurrence. 
 
 Case 27. — L. R , ?etat forty-five; married, three 
 
 children. Os and cervix implicated, hard, and very painful. 
 Sanious offensive discharge from os. Vagina free. Supra- 
 vaginal amputation with cone-shaped piece on February 16, 
 
55 
 
 1892. Discharged April 9. Wound healed ; no dis- 
 charge. 
 
 Case 28. — E. H , astat forty-seven ; married, thirteen 
 
 children. Whole os implicated, and bleeds readily. Vagina 
 free. Supra-vaginal amputation March 26, 1892. Discharged 
 April 23 ; wound healed. 
 
 Case 29. — M. B , setat forty-four ; married, five 
 
 children; admitted March 23, 1892, with pronounced 
 cancer of os. Supra- vaginal amputation performed March 26. 
 Discharged, wound healeJ, on June 11, 1892. 
 
 Case 30. — E. M , retat forty-five ; married, seven 
 
 children; admitted July i, 1892. Has noticed a discharge 
 for some months ; of late it has been blood-stained at times. 
 On examination a cauliflower excrescence is found to be 
 growing from the os. The vaginal walls are not implicated. 
 Supra-vaginal amputation on July 12, 1892. Discharged 
 August 4. 
 
 Case 3 1 . — A. R , setat thirty-seven ; married, nine 
 
 children ; admitted November 14, 1892, with carcinoma 
 of cervix. Has a good deal of discharge and pain. Os 
 hard and ulcerated. Supra-vaginal amputation November 19, 
 1892. Discharged January 13, 1892 ; no recurrence. 
 
 Ill the year 1893 I performed two operations. 
 
 Case 32. — A. W , setat forty-eight; married, eight 
 
 children ; admitted May 22, 1893, with carcinoma of cervix. 
 Has had offensive discharge for some months. Extensive 
 ulceration of os, extending up cervical canal. Vagina walls 
 free ; uterus freely movable. Supra-vaginal amputation 
 May 24, 1893. Douglas's pouch was opened July 15. 
 Patient discharged well ; no discharge or pain. 
 
 Case 33. — E. A , setat thirty-two ; married, five 
 
 children, youngest five years old; admitted July 31, 1893, 
 with large cauliflower excrescence springing from os and very 
 offensive discharge ; bleeds readily ; vagina free. August i 
 supra-vaginal amputation was performed. Douglas's pouch 
 was opened, a glass drainage-tube inserted, and vagina 
 packed with iodoform gauze. September 21, patient dis- 
 charged, wound healed, no sign of disease ; recurrence 
 some months later. 
 
 Case 34. — A. H , setat thirty-five ; single ; admitted 
 
 January 29, 1894. Carcinoma of os and cervix. Vagina 
 
56 
 
 free; uterus movable. Discharge sanious. January 31, 
 1894, supra-vaginal amputation. Discharged March i, 
 quite healed ; no recurrence. 
 
 Cc7Sf 2,S- — E. B ,»tat forty-two ; married, five children ; 
 
 admitted February 13, 1894. Os deeply ulcerated ; cervix 
 hard and indurated ; bleeds readily. Vagina not implicated ; 
 uterus freely movable. February 13 supra-vaginal amputa- 
 tion of OS and cervix. Patient made uninterrupted recovery, 
 and was discharged on March 7, quite healed, and no pain 
 or discharge. 
 
 Case 36. — M. B , setat thirty-seven ; married, three 
 
 children ; admitted February 13, 1894. Extensive ulceration 
 of OS and cervix ; considerable pain and discharge, occasion- 
 ally blood-stained. March 7, supra-vaginal amputation 
 performed. Patient discharged April 7, wound quite 
 healed. 
 
 Case 37. — H. O , aetat forty; widow, four children ; 
 
 admitted April 14, 1894. Cauliflower growth springing 
 from OS. Discharge very offensive. Vagina quite free ; 
 uterus movable. On April 18 supra- vaginal amputation of 
 OS and cervix. Patient made an excellent recovery, and was 
 discharged May lo, wound quite healed. 
 
 Case 38. — A. G , setat thirty-six ; widow, three 
 
 children, one miscarriage; admitted on May 11, 1894. 
 Carcinoma of os and cervix. Suffers considerable pain. 
 May 15 supra-vaginal amputation of os and cervix per- 
 formed. Patient convalesced somewhat slowly, and was 
 discharged on June 22, well. 
 
 Case 39. — E. P , ffitat forty ; married, six children ; 
 
 admitted May 16, 1894. Os deeply ulcerated, disease 
 extending up the cervical canal. Bleeds readily on ex- 
 amination. Discharge very copious and offensive. May 22 
 supra-vaginal amputation. Discharged well on June 30. 
 
 Such are the brief histories of these cases, of which twenty- 
 eight recovered, and have had no signs of recurrence at the 
 present. The time which has elapsed since the operation 
 in these cases varies from one to three years. One case 
 recovered from the operation, and remained free from re- 
 currence for over two years, when the disease reappeared. 
 In five cases, recurrence took place within a year of the 
 operation. Two cases were lost sight of, but were free from 
 recurrence when last seen, some time after the operation. 
 
57 
 
 Two cases died, one from pelvic cellulitis and another from 
 exhaustion. This latter case should hardly have been in- 
 cluded in the series, as the disease was far too extensive to 
 allow of anything but a palliative operation. 
 
 From these cases, I think, a valuable lesson may be learned, 
 and I purpose to make a few remarks respecting cases 5, 7, 
 9, 10, 12, 19, and 21. In all these cases recurrence took 
 place within a few months after the operation, or the patients 
 died. It may be taken, therefore, that they were not bene- 
 fited in any way by the operation ; and it may be assumed 
 that they were cases unsuitable for this form of operation. 
 
 In Case 5 we find the disease is said only to have existed 
 for five months, and digital examination merely discovered 
 some induration of the os and cervix, and a slightly enlarged 
 uterus, not very mobile. The speculum revealed some 
 superficial ulceration. Here is a case in which, if the true 
 significance of the enlarged and slightly-fixed uterus had 
 been fully appreciated, such an operation as partial removal 
 of the viscus would not have been attempted, as it is obvious 
 from the very speedy recurrence of the disease that, although 
 the cervix was thought only to be implicated, yet, in all 
 probability, the disease commenced in the endometrium. 
 In such a case the only operation that was at all likely to be 
 of permanent service would have been total extirpation of 
 the uterus, and even in such an operation some difficulty 
 would have been encountered owing to the fixation. 
 
 Case 7 had noticed an offensive discharge for eight 
 months. Here there was no ulceration of the os, but the 
 cervix was enlarged and indurated. The uterus was freely 
 movable. In this case there can be no doubt but that 
 the disease commenced in the cervical canal, and, instead 
 of extending downwards towards the os, as usually is the 
 case, it passed upwards to the mucous membrane lining the 
 body of the uterus. In removing the conical piece, while 
 apparently the incision was carried well beyond the disease, 
 there must have been some foci of malignant growth, 
 extending either deeply into the muscular tissues or into 
 the mucous surface, which was not removed. In this case, 
 I think, vaginal hysterectomy would have been the better 
 operation, or the cavity of the uterus should have been 
 thoroughly curetted and packed with chloride of zinc wool. 
 
 Case 9 had a large cauliflower growth springing from the 
 
S8 
 
 OS. The uterus was freely movable, and this, in my opinion, 
 was a suitable case for supra- vaginal amputation. Probably, 
 however, from the long contact with this foul growth, the 
 mucous membrane of the vagina became impregnated with 
 the septic discharge, and, notwithstanding the most scrupu- 
 lous care, and use of antiseptic applications, the wound caused 
 by the operation became infected, and pelvic cellulitis fol- 
 lowed. In such cases, perhaps it would have been wiser to 
 have introduced a glass drainage-tube, and packed the 
 vagina with some antiseptic gauze. 
 
 Case lo had all the appearance of being a favourable case 
 for the high operation ; here, however, as in Case 7, the 
 disease had evidently extended more deeply than was antici- 
 pated. No doubt, total extirpation would have been a 
 preferable operation in this case. 
 
 Case 12. — Here again the uterus was somewhat fixed, and 
 undoubtedly these cases are unsuitable for operation. 
 
 In Case 19 the vagina was involved to a slight extent, 
 and a large cauliflower growth occupied the vagina. The 
 patient was very reduced by septic absorption and loss 
 of blood during the operation, which was undertaken 
 purely as a palliative measure to relieve the poor woman 
 of a putrid, badly-smeUing mass. This case can hardly be 
 included as one in which the high operation only had been 
 performed. 
 
 Case 2 1, owing to the extent of the disease, would have 
 been better treated by complete extirpation ; permission, 
 however, for doing this had not been obtained, so that the 
 course which, in my opinion, would give her the next best 
 chance of getting rid of the disease was adopted. 
 
 Remarks. — In the first place, I think it will be well to 
 define my meaning of the term supra-vaginal amputation. 
 It is not the mere amputation of the cervix, but the removal 
 of the cervix with a large cone-shaped piece above from the 
 body of the uterus. 
 
 I am quite in accord with Dr. John Williams, Schroeder, 
 and Hoffmeier, whose statistics go conclusively, I think, to 
 show that where carcinoma of the uterus is seen early, and 
 the disease is limited to the vaginal portion of the organ, 
 supra-vaginal amputation is all that is necessary, and it is 
 useless to put patients to the extra risk of total extirpation 
 of the uterus. Gusserow gives the mortality after supra- 
 
59 
 
 vaginal amputation when performed by the knife at 9*09 per 
 cent., and when by the galvanic cautery at 7-75 per cent., 
 while Post, in \\\q. American Journal of Obstetrics^ November, 
 1887, in 700 cases of vaginal hysterectomy he had collected, 
 asserts that the mortality after this operation is 24 per cent. 
 Since these statistics were collected, no doubt, the methods 
 adopted for the removal of the uterus per vaginam are much 
 improved, but even now Martin of Berlin gives his mor- 
 tality at i6"6 per cent., while, however, Leopold and 
 Scengen acknowledge to a mortality of only 6 '2 and 8 '3 per 
 cent, respectively. There can be no doubt, I think, that 
 the deaths after supra-vaginal amputation are considerably 
 less than after vaginal hysterectomy, and, in suitable cases, 
 I think I have shown that the results obtained are such as 
 to warrant us in advising the former operation in preference 
 to total extirpation in suitable cases. 
 
6o 
 
 TWENTY-EIGHT CASES OF VAGINAL HYSTERECTOMY FOR 
 CARCINOMA, AND TWO FOR MYOMA OF THE UTERUS, 
 WITH TWO DEATHS. 
 
 A paper in which these cases were recorded was read by 
 me at the British Medical Association meeting at Bristol, 
 August, 1894. Before recording these cases, I will give a 
 short description of the clamp referred to on page 37. It 
 occasionally happens in performing vaginal hysterectomy 
 that one meets with a case in which the broad ligaments are 
 very short and somewhat thickened, in consequence of which 
 the tilting of the uterus, by either retro- or ante-version, is 
 rendered very difficult. In such cases the application of 
 the ligature is most difficult. It is in such instances that 
 compression forceps may be of considerable value. Messrs. 
 
 Weiss and Son have made for me some forceps, which I 
 think are well suited to these cases ; they are light, and at 
 the same time strong. By reference to the engraving, 
 it will be seen that they are composed of two distinct 
 portions, one furnished with a pin at the point of union, 
 and the other being deeply notched out so as to work 
 around the pin. The blades are so arranged that one has a 
 centre-bar, which is slightly deeper at the distal end than at 
 the proximal, and extending the whole length of the blade 
 there is a corresponding depression in the opposing blade 
 into which this bar fits. By this arrangement, when the 
 forceps are securely closed, the thinner tissues at the upper 
 
6i 
 
 part of the broad ligament, as well as the thicker parts at 
 the vaginal end, are firmly gripped, and I believe it would 
 be impossible for either the uterine or ovarian artery to slip. 
 
 The blades being made separately enables the operator to 
 introduce one blade at a time if he wishes, and this separa- 
 tion of the blades is also of service in enabling the forceps 
 to be kept absolutely aseptic. 
 
 I am indebted to Mr. West, my house-surgeon, for the 
 notes of all the cases which occurred in the Cancer 
 Hospital. 
 
 Case I. — A. C , aetat thirty-seven; married, no 
 
 children ; consulted me on March i8, 1892, complaining of 
 offensive discharge, sometimes blood-stained ; first noticed 
 discharge a year ago ; has lost much flesh. 
 
 Present Condition. — A growth of considerable size, hard, 
 ulcerated in places, occupies the os ; bleeds readily, and 
 causes much pain ; uterus somewhat enlarged. Vaginal 
 hysterectomy performed by me March 25 ; patient made 
 excellent recovery, and is at present free from recurrence. 
 Microscopic examination — carcinoma. 
 
 Case 2. — M. E , setat fifty-three ; married, six 
 
 children ; admitted under my care into Cancer Hospital 
 July 4, 1892, complaining of pain in back and left iliac 
 region. Patient has had a badly-smelling discharge for ten 
 months, with slight hsemorrhage ; menopause six years ago. 
 
 Present State. — There is a cauliflower growth springing 
 from the os, which has ulcerated, and bleeds readily on ex- 
 amination. Vaginal wall quite free ; uterus freely movable. 
 
 July ID. — Vaginal hysterectomy performed. Patient 
 made an excellent recovery, and is at the present time free 
 from recurrence. Microscopic examination — carcinoma. 
 
 Case 3. — W. C. S , getat forty-six ; married, five 
 
 children; consulted me July, 1892, suffering from slight 
 discharge, which had lasted about six months ; about three 
 months ago had haemorrhage, which has recurred from time 
 to time since. 
 
 Present State. — Os ulcerated and widely dilated, readily 
 admitting finger; bleeds readily, and, indeed, somewhat 
 profusely. A smooth, soft substance is felt in uterus ; 
 uterus movable, but the left broad ligament appears some- 
 what thickened. 
 
 July 7. — Vaginal hysterectomy performed; microscopic 
 
examination — medullary carcinoma. Patient free from 
 disease present time. 
 
 Case 4. — E. B , retat thirty-eight : admitted into the 
 
 Cancer Hospital December 22, 1892, suffering from car- 
 cinoma of the uterus ; sent to me by Mr. Scharlieb, M.D. 
 Patient is married, has had four children, and one mis- 
 carriage ] no family history of cancer. Patient had inflam- 
 mation of the uterus six years ago ; has never felt strong 
 since ; had a thin watery discharge till six months ago, 
 when she had a severe flooding, and since this the discharge 
 has been blood-stained and very offensive ; suffers great 
 pain ; says she has not lost flesh. 
 
 Jamiary 2,-, 1893. — Vaginal hysterectomy performed ; dis- 
 charged convalescent February 25, 1893. 
 
 July, 1894. — She presented herself for examination, when 
 slight recurrence was discovered. 
 
 Case 5. — L. P , setat fifty-seven; married, two 
 
 children; consulted me in October, 1892, complaining of 
 hsemorrhage and bearing-down pains ; menopause ten years 
 ago. 
 
 Present State. — There is slight discharge coming from 
 the uterus, not offensive ; uterus retroflexed, but not, appar- 
 ently, enlarged ; sound is passed with some little difficulty, 
 and causes haemorrhage. Microscopic examination — adeno- 
 carcinoma. 
 
 October 27. — Vaginal hysterectomy performed; made 
 good recovery ; no recurrence at present. 
 
 Case 6. — A. K , setat thirty -six ; married, no 
 
 children or miscarriages ; admitted into the Cancer Hospital 
 May 15, 1893 ; under my care ; suffering from carcinoma of 
 the cervix. Patient sent by Dr. Heywood Smith. 
 
 History from Patient.- — Patient has had pain in the lower 
 part of abdomen and in the back for the last eight months ; 
 had discharge for the same period, which has latterly 
 become more watery and offensive. Patient had a severe 
 flooding April 10, 1893, other floodings less severe since. 
 
 Family History. — Mother died of cancer of the throat, 
 age forty-two; no other history of malignant disease or of 
 tumour. 
 
 Present Condition. — Healthy-looking woman, and fairly 
 well nourished. In the situation of external os is an ulcer 
 admitting the forefinger for about an inch ; the walls of 
 
63 
 
 cavity are formed by hard tissue, which extends more to the 
 left side ; vaginal walls are free ; the uterus bimanually 
 appears freely movable, though the left broad ligament 
 appears slightly involved ; examination causes some bleed- 
 ing. 
 
 May i6, 1893. — Vaginal hysterectomy was performed; 
 disease was more extensive on the left side ; the whole of the 
 uterus was removed ; about half an inch of the left ureter 
 was removed with the growth. Patient lost little blood; 
 all the forceps were removed. Vagina was packed with 
 iodoform gauze. The ovaries and tubes were not removed. 
 Operation lasted about an hour and a quarter. 
 
 Patient made a good recovery, although urine still escaped 
 by the vagina. She was furnished with a pessary with an 
 indiarubber funnel, which was conducted into a urinal 
 fastened round leg, and discharged May 31, 1893. '^he 
 disease recurred in a few months. 
 
 Case 7. — C. J. E , setat forty-two; has been a widow 
 
 for the last six years, no children ; admitted into the Cancer 
 Hospital June 24, 1893; under my care; suffering from 
 uterine carcinoma. Sent by Dr. Pedler. 
 
 History from Fatie?it. — Patient has been always regular 
 every month, until two and a half years ago, when she lost 
 a good deal of blood and clots per vaginam, and had much 
 pain ; , has lost much strength and flesh. Dr. Heywood 
 Smith, three weeks ago, dilated the os and curetted the 
 uterine cavity ; the scrapings were examined microscopically 
 by Dr. Bousfield, who pronounced the growth to be an 
 encephaloid carcinoma. 
 
 Present Condition. — Patient is an anaemic, poorly-nourished 
 woman ; the cervix uteri is normal, but the body of the 
 uterus is enlarged to about the size of a large orange, appears 
 hardish and globular, freely movable; the left broad ligament 
 feels thicker than normal. 
 
 July I, 1893. — Under ether vaginal hysterectomy was per- 
 formed. The vagina was very small, and the uterus being 
 enlarged, it was difficult to remove. It not being possible 
 to antevert or retrovert the organ, it was pulled straight 
 down ; the broad ligaments each side were tied with silk, 
 the ovaries were not removed. The uterus after removal 
 was much enlarged, about the size of a small cocoa-nut. 
 On section the uterine walls were considerably thickened, a 
 
64 
 
 whitish, somewhat hard growth was seen surrounding the 
 uterine cavity, soft matter, looking hl<e brain substance, 
 occupying the place of the mucous lining of uterus. 
 
 1 saw the patient in about eight months with Dr. Pedler, 
 when her left leg was much swollen, and there was a tumour 
 in the abdomen, evidently malignant, and she died nine 
 months after the operation. 
 
 Case 8. — E. S , aetat fifty-two ; married, three children ; 
 
 consulted me, July, 1893, suffering from a badly smelling 
 discharge. Menopause four years previously. She had 
 had bleeding from time to time, especially when riding in 
 cabs or omnibuses ; has suffered a good deal of pain. 
 Microscopic examination — round-celled sarcoma. 
 
 Prese7it State. — A growth is seen projecting from the os, 
 soft, and bleeding readily. Uterus quite movable, and not 
 enlarged. Vaginal walls not implicated. 
 
 Jidy 30. — Vaginal hysterectomy performed. Patient 
 made an excellent recovery ; no recurrence. 
 
 Case 9. — H. D , getat fifty -eight; married, six 
 
 children; consulted me February, 1893, for a disagreeable 
 badly-smelling discharge. On examination the os was found 
 to be eroded and deeply fissured, the cervix hard ; and on 
 passing the sound the endometrium was found to be 
 roughened. The menopause had occurred ten years pre- 
 viously, and before seeing me she had had frequent admix- 
 ture of blood with the discharge. On February 20 I 
 performed vaginal hysterectomy. Patient made an excellent 
 convalescence. On opening the uterus a growth was dis- 
 covered, which on microscopic examination was pronounced 
 to be adeno-carcinoma. No recurrence. 
 
 Case 10. — S. J , setat sixty-three; single; was seen 
 
 by me in consultation with Dr. Gross in July, 1893. I had 
 previously removed some growth from the uterus of this 
 patient, which proved to be round-celled sarcoma. In con- 
 sultation with Dr. (now Sir) John Williams and Dr. Gross, 
 it was agreed that vaginal hysterectomy should be advised ; 
 this the patient agreed to, and on July 6 I removed the 
 uterus per vaginam. Owing to the smallness of the vagina 
 I divided the perinjeum. The patient made a good con- 
 valescence, but the disease recurred in the left broad liga- 
 ment in about three months after the operation. She died 
 within six months. 
 
65 
 
 Case II, — Mrs. H , retat thirty-five; married, two 
 
 children ; was sent to me by Dr. CuUingworth in July, 
 1893. Patient had had discharge for eighteen months, and 
 bleeding from time to time. Suffered great pain at bottom 
 of back. 
 
 Present Condition. — A large ulcerated surface occupies 
 position of os, extending to vaginal roof ; bleeds on examina- 
 tion ; badly-smelling discharge ; uterus movable, but the 
 disease appears to have infiltrated the cellular tissue around 
 cervix. Microscopic examination — sarcoma. 
 
 On July 17 I performed vaginal hysterectomy. Patient 
 did very well for first two days, then symptoms of septic 
 peritonitis set in, and patient died on the fifth day. 
 
 Case 12. — Mrs. S , setat fifty-five; married, three 
 
 children ; menopause about five years ago ; sent me by 
 Mrs. Garrett Anderson, who saw her in July, 1893. She 
 had been suffering from discharge for some months, and 
 had recently a good deal of haemorrhage. Mrs. Garrett 
 Anderson dilated the os and removed a small piece of 
 growth with the curette, which microscopic examination 
 proved to be malignant. I performed vaginal hysterectomy 
 on July 7. The patient made an excellent recovery. 
 
 This patient came to see me in April, 1894, suffering 
 from intestinal obstruction. She had a hard nodule situated, 
 apparently, on the ascending colon. As the symptoms were 
 urgent I advised immediate abdominal section. On open- 
 ing the abdomen the nodule referred to was evidently 
 malignant; there was a second growth also found at the 
 junction of the descending colon and the sigmoid flexure. 
 I fastened the caecum to the abdominal wound, and opened 
 it the next morning. The patient sank, however, from ex- 
 haustion. No recurrence of disease locally. 
 
 Case 13. — E. A , setat thirty-two ; admitted into the 
 
 Cancer Hospital on July 31, 1893 ; under my care ; suffer- 
 ing from uterine carcinoma ; sent me by Dr. Butler Smythe. 
 Patient is married, and has had five children ; no mis- 
 carriages ; the last child five years ago. Patient has had 
 vaginal discharge, at times stained with blood, for the last 
 five or six months ; has had severe pain in the back and 
 lower part of abdomen for the last three months. 
 
 Present Condition. — Fairly healthy, though poorly- 
 nourished woman. In the situation of external os is an 
 
66 
 
 ulcerated cavity admitting the tip of forefinger. Uterus 
 movable ; the ulcerated surface extends more to the left ; 
 examination causes some bleeding. 
 
 August I. — Vaginal hysterectomy was performed ; glass 
 drainage-tube inserted into wound of peritoneum ; vagina 
 packed with iodoform gauze. 
 
 September 21. — Patient discharged well, without pain or 
 discharge ; wounds in vaginal roof quite healed. 
 
 Case 14. — E. D , setat fifty-seven ; admitted into the 
 
 Cancer Hospital August 1, 1893 ; under my care; suffering 
 from uterine carcinoma. Sent by Dr. Heywood Smith and 
 Dr. Hunter. 
 
 History. — Patient is married, and has had four children 
 and three miscarriages ; the last pregnancy was fifteen years 
 ago. Patient has had vaginal discharge for the last year ; 
 for the last six months patient has noticed blood occasion- 
 ally in the discharge ; for the last fortnight discharge has 
 become more watery and offensive. Has lost much flesh, 
 and has had much pain in the lower part of abdomen and 
 back latterly. 
 
 Present Conditmi. — Healthy-looking and well-nourished 
 woman. In the situation of external os is an ulcer ad- 
 mitting the tip of the forefinger ; uterus freely movable ; 
 examination causes some bleeding ; the walls of ulcer are 
 formed by hard tissue. 
 
 August 5, 1893. — Vaginal hysterectomy was performed. 
 Patient recovered without a bad symptom, and was dis- 
 charged September 9, without any pain or discharge, wound 
 quite healed. Patient has gained 8 lb. in weight during her 
 stay in the hospital. 
 
 In November patient consulted me again, suffering from 
 violent vomiting. On examination stomach was found 
 much dilated, and a distinct tumour, the size of a small 
 apple, could be felt at the situation of the pylorus. The 
 vaginal roof was quite healthy, and no growth could be felt 
 in the pelvis ; the patient gradually sank. A post-mortem 
 was declined, but presumably she died of carcinoma of the 
 pylorus, or enlarged glands pressing on the pylorus. No 
 recurrence of disease locally. 
 
 Case 15. — M. I , jetat forty-one; married, two 
 
 children; consulted me August 2, 1893, complaining of 
 disagreeable discharge and occasional haemorrhage, accom- 
 
67 
 
 panied by constant bearing-down pains and irritation of the 
 bladder. 
 
 Present State. — Os deeply ulcerated; cervix hard and 
 resisting, bleeding freely on examination ; discharge offen- 
 sive ; vagina free ; uterus freely movable. Vaginal hysterec- 
 tomy, August 1 2 ; patient made rapid recovery ; no recur- 
 rence ; microscopic examination— epithelioma. 
 
 Case i6. — C. L , eetat forty-five; married, no 
 
 children; consulted me September, 1893, suffering from 
 haemorrhage. Patient says she has had slight discharge for 
 some little time. Of late between the periods has had 
 sudden gushes of blood after any exertion ; examination 
 with sound causes bleeding; sound enters just over normal 
 distances ; microscopic examination — adeno - carcinoma. 
 Vaginal hysterectomy performed September 26. Patient 
 made a good recovery, and is now free from recurrence. 
 
 Case 17. — M. J — — , astat thirty three ; was admitted 
 under my care into the Cancer Hospital in October, 1893, 
 suffering from sarcoma of the uterus. Patient has been 
 married eleven years ; has had two children and two mis- 
 carriages ; the last pregnancy was three years ago, which 
 terminated in a miscarriage, the patient being then five 
 months pregnant. Sent to me by Dr. Barbour. 
 
 Present Condition. — Patient is losing blood from uterus in 
 considerable quantity ; no tumour is palpable in abdomen ; 
 per vaginam the cervix is enlarged ; no ulceration or erosion 
 visible by the speculum ; blood is seen coming from external 
 OS ; bimanually the uterus feels enlarged to about the size of a 
 small cocoanut, freely movable ; the sound passes 3^ inches. 
 
 October 10. — Patient was placed under the influence of 
 ether, and the cervical canal was dilated with Hegar's 
 dilators to No. 24 ; the finger was introduced into the 
 uterine cavity; the mucous membrane felt roughened in 
 places, and very hard. A small polypus about the size of a 
 filbert nut was felt at the fundus uteri. The interior of 
 uterus was then scraped with a curette, and the uterus was 
 washed out. A microscopic examination of scraping proved 
 the growth to be a round-cell sarcoma. 
 
 October 13. — As a result of the microscopical examina- 
 tion patient was strongly advised to have hysterectomy 
 performed, to which she consented. On October 13, under 
 ether, the uterus was removed through the vagina. 
 
'68 
 
 The uterus on removal appeared more globular in shape 
 than normal, and about the size of a two months' pregnancy, 
 the peritoneal coat appearing normal. On section the walls 
 of the uterus were considerably thickened. Patient made 
 an excellent recovery, and is still free from any recurrence. 
 
 Case 1 8. — A. S , setat forty-seven; married, three 
 
 children ; was sent to me by Dr. Barnes, suffering from 
 discharge and haemorrhage, December, 1893. 
 
 Present State. — Well-defined irregular growth from cervix, 
 extending upwards in cervix ; ulcerated, and bleeding readily 
 on examination ; some thickening in broad ligament ; body 
 of uterus rather larger than normal. Vaginal hysterectomy 
 December 13, 1893. Patient made an excellent recovery, 
 and has had no recurrence. 
 
 Case 19. — A. G , stat fifty-two ; admitted on 
 
 December ir, 1893, into the Cancer Hospital, suffering 
 from cancer of the body of the uterus. 
 
 History. — Patient has been a widow for the last thirty 
 years ; had one child thirty years ago. For the past three 
 years has had a blood-stained discharge, and has had 
 several rather severe losses of blood during this period. 
 Just before the discharge came on patient had been quite 
 regular every month. In November, 1893, patient was 
 under the care of Dr. Heywood Smith. She was then 
 anaesthetized, the uterus explored, and some growth re- 
 moved for microscopical examination, which subsequently 
 proved to be cancerous. 
 
 Past History. — Patient had her breast amputated six 
 years ago at St. George's Hospital by Mr. Pickering Pick ; 
 very extensive scar now present ; no recurrence of disease. 
 
 Present Condition. — Fairly well-nourished woman. On 
 vaginal examination by means of a Ferguson's speculum, 
 the OS is hard, with everted lips, blood-stained, and some 
 very offensive discharge seen issuing from external os. On 
 bimanual examination the uterus feels slightly enlarged, 
 though freely movable ; sound not passed. 
 
 December 12, 1893. — Vaginal hysterectomy performed. 
 Patient made an excellent recovery, and on January 13 was 
 discharged convalescent. The disease recurred in six 
 months after operation. 
 
 Case 20. — F. St. ' J , retat forty-four; admitted on 
 
 January 4, 1894, under my care, into the Cancer Hospital, 
 
69 
 
 suffering from cancer of the uterus. Complains of great 
 pain in the lower part of abdomen. Per vaginam the cervix 
 feels hard, and os thickened and eroded. Body of uterus 
 feels enlarged. Some bosses felt on the posterior suiface 
 of uterus ; sound passes 3! inches. Some foul vaginal 
 discharge. 
 
 January 9, 1894, — Under ether, vaginal hysterectomy 
 performed. Both ovaries and tubes also removed. 
 
 February 14. — Patient discharged ; wound quite healed. 
 No recurrence of disease. 
 
 Case 21. — A, M , setat thirty-one; admitted into 
 
 the Cancer Hospital on January 29, 1894 ; under my care ; 
 suffering from carcinoma of the cervix. No family history 
 of cancer. 
 
 History. — Patient is married, has had four children, the 
 last child born five years ago. Has suffered from foul 
 vaginal discharge for the last three or four months ; the 
 discharge has latterly become stained with blood. Has 
 had very little pain, and states she has not lost flesh latterly. 
 
 Presejit Condition. — Very pale, anaemic-looking woman. 
 On vaginal examination there is a large cauliflower growth 
 on the cervix. The disease extends rather more on the 
 right side ; uterus freely movable ; vagina not diseased. 
 
 Operation. — On January 30, 1894, under ether, vaginal 
 hysterectomy was performed. Patient made a good re- 
 covery, and was discharged February 28. The disease 
 recurred within six months. 
 
 Case 22. — E. J. C , setat sixty-two ; admitted into the 
 
 Cancer Hospital on February 10, 1894, suffering from 
 sarcoma of the body of the uterus. 
 
 Family History. — Mother died of cancer of the liver. 
 
 History. — Patient has had a very offensive discharge and 
 pain in the back and lower part of abdomen for the last 
 six months. On November 27, 1893, at the Samaritan 
 Hospital, the cervical canal was dilated and the uterus 
 explored; some soft growth was scraped away for micro- 
 scopic examination, which subsequently proved to be 
 malignant. 
 
 Present Condition. — Very emaciated-looking woman ; 
 heart and lungs normal. On vaginal examination the 
 vaginal canal was found to be very small. The cervix feels 
 healthy, and the uterus bimanually is freely movable, and 
 
70 
 
 not appreciably enlarged ; examination causes much pain. 
 There is a foul discharge ; the speculum not used, on 
 account of smallness of vagina. 
 
 February 20. — Under ether vaginal hysterectomy was 
 performed ; the perinfeum was first divided, on account of 
 the smallness of vaginal outlet. Unfortunately, in this case 
 the recto-vaginal septum was torn, and a fistula estab- 
 lished. This was closed subsequently by operation. On 
 section of the uterus, which was only slightly enlarged, 
 there was a diffuse soft growth, forming more or less 
 irregular projections on the surface of the mucous mem- 
 brane. The growth was most abundant near the orifices of 
 the Fallopian tubes. 
 
 I'ebriiary 28. — Patient rapidly recovering. Patient con- 
 tinues free from any recurrence. 
 
 Case 23. — E. C , aetat forty-four; admitted into the 
 
 Cancer Hospital on February 19, 1894; under my care; 
 suffering from epithelioma of the vulva and carcinoma of 
 the cervix uteri. No family history of cancer. Patient has 
 been married twenty-three years, has had thirteen children, 
 no miscarriages ; the last child four and a half years ago ; 
 has had vaginal discharge for the last six months, which 
 latterly has become more watery and offensive. Patient first 
 noticed growth of vulva about six months back, which has 
 been growing steadily since ; has lost much flesh and 
 strength lately ; has suffered very little pain. Sent to me 
 by Dr. Sunderland. 
 
 Present Condition. — Fairly well-nourished woman. In 
 the left labium is a growth about the size of a hen's egg ; 
 the growth has ulcerated, and has hard everted and sinuous 
 edges. Per vaginam, in the situation of external os, is an 
 ulcerated cavity, admitting the tip of the finger ; the walls 
 of cavity are formed by hard tissue ; the uterus is freely 
 movable, and the vagina is free from disease. 
 
 Febriia?y 27. — Under ether the growth from the vulva 
 was first freely excised. Vaginal hysterectomy was then 
 performed. 
 
 Patient made an excellent recovery, and was discharged 
 March 21. Patient is free from recurrence. 
 
 Case 24. — L. M , ostat forty-seven; single; admitted 
 
 on March 7, 1894, under my care, into the Cancer Hospital, 
 suffering from carcinoma of cervix uteri. No family history 
 of cancer. 
 
71 
 
 History. — Patient has had a foul discharge from the 
 vagina for the last eight months, which latterly has become 
 more watery and is sometimes blood-stained ; has suffered 
 very little pain. Saw Dr. Cullingworth at St. Thomas's 
 Hospital in February, 1894, who sent her to me. 
 
 Present Condition. — Somewhat advanced cancer of cervix 
 uteri ; uterus not fixed ; disease extends more to the left 
 side. 
 
 March 13, 1894. — Under ether vaginal hysterectomy per- 
 formed. 
 
 April 13. — Patient discharged, wound firmly healed ; 
 no discharge or pain. Disease recurred in this case some- 
 what rapidly. 
 
 Case 25. — E. B , setat thirty-one; married, six 
 
 children, youngest two years; admitted on March 8, 1894, 
 into the Cancer Hospital; under my care ; suffering from 
 cancer of the uterus. 
 
 Family History. — Uncle, on father's side, had cancer of 
 stomach. 
 
 History. — Has had foul vaginal discharge since November, 
 1893 ; has had pain in lower part of abdomen for the last 
 month ; a large cauliflower growth of cervix ; uterus freely 
 movable ; vaginal walls not affected with disease. 
 
 March 13. — Under ether vaginal hysterectomy per- 
 formed. The uterus was easily pulled down with vulsella 
 forceps ; uterine arteries tied with silk ; the cut edges of 
 peritoneum were pulled down with forceps ; glass drainage- 
 tube used, and vagina packed around tube with iodoform 
 gauze ; operation lasted half an hour. 
 
 March 14. — Glass drainage-tube removed. 
 
 March 15. — Iodoform gauze removed. 
 
 March 17. — Patient very sick and somewhat collapsed; 
 bowels not open since operation ; ordered gss. of sodii 
 sulphatis in hot water. 
 
 March 18. — Bowels still not open ; vomiting more severe ; 
 some abdominal distension ; no tenderness ; ordered an 
 enema. 
 
 March 19. — Patient getting worse; vomiting and 
 abdominal distension more severe ; vomiting not fsecal. 
 Abdominal section performed ; a portion of small intestine 
 was discovered strangulated by a piece of adherent omen- 
 tum. The gut was released, and the omentum was ligatured 
 
72 
 
 in two or three places and cut off. The peritoneal cavity 
 was washed out with salt solution. Keith's drainage tube 
 was used. 
 
 March 20. — Patient died from shock \ no peritonitis at 
 post-mortem examination. 
 
 Case 26. — S. M , setat fifty-four ; married, ten chil- 
 dren and two miscarriages ; admitted on May 30, 1894, 
 under my care, into the Cancer Hospital, suffering from 
 cancer of the body of uterus. No family history of cancer. 
 
 History. — Patient has had a foul vaginal discharge for the 
 last eighteen months, and for the past three months has had 
 much pain in the lower part of the abdomen ; was in the 
 Sussex County Hospital, Brighton, during March, 1894, 
 under Dr. Paley's care, who is reported to have removed 
 some scrapings from interior of uterus, which microscopic 
 examination proved to be cancerous. 
 
 Present Condition. — Cervix feels small and atrophied ; 
 body of uterus felt bimanually feels very hard ; movable ; 
 not enlarged ; blood-stained discharge from os. 
 
 April 10. — Under ether vaginal hysterectomy performed. 
 
 May 3. — Patient discharged; wound firmly healed. 
 
 Case 27.- — F. R , setat fifty-seven; married, three 
 
 children. Dr. Walker asked me to see this patient with 
 him in April, 1894. Patient always enjoyed good health 
 until four years ago, when she had some violent haemorrhage 
 and she felt a tumour in her abdomen. She consulted a 
 speciahst for this, and a fibroid sloughed from the uterus. 
 From that time until a few months ago she kept fairly well, 
 when she noticed a discharge, and experienced a good deal 
 of pain in getting about. 
 
 Present State. — There is a well-marked tumour, readily 
 felt, deeply situated in the pelvis ; the parietes are flaccid, 
 and admit of ready examination ; the os feels healthy, no 
 erosion or ulceration ; uterus readily movable. The growth 
 is evidently in the body of the uterus. There is a sanious, 
 badly-smelling discharge from os. Sound passes four 
 inches. 
 
 Combined vaginal and abdominal hysterectomy performed 
 on April 19. The combined operation was necessitated 
 from the size of the growth. The patient made an excellent 
 recovery, and is now able to get about well, and is free 
 from recurrence. Microscopic examination — sarcoma. 
 
73 
 
 Ciise 28. — S. L -, setat fifty-six ; married, three chil- 
 dren ; consulted me in April, 1894; has suffered for some 
 time from hsemorrhage at intervals. Menopause nine years 
 ago. 
 
 Present Condition.— O^ papulous ; body of uterus enlarged, 
 and somewhat soft to the touch ; bleeds readily ; cervix 
 slightly dilated \ no ulceration or erosion of os. 
 
 Vaginal hysterectomy April, 1894. Patient made an un- 
 interrupted recovery, and is now quite free from any sign of 
 recurrence. 
 
 Case 29.— H. K— — , setat fifty- four, was admitted to 
 the Cancer Hospital, under my care, on July 8, 1893, suffer- 
 ing from a large fiWo-myoma of the uterus. Patient is 
 married, and has eight children \ the last child was born 
 twelve years ago. 
 
 History of Illness,— ?z.\Xqx\.\. has had swelling of abdo- 
 men, and constant attack of hsemorrhage from the vagina, 
 for the last twelve or thirteen years. The attacks of hsemor- 
 rhage latterly have become much more frequent and more 
 severe, and are seriously undermining patient's health. 
 
 Fresejit Co?idition. — Patient is a fairly well-nourished 
 woman of average height, markedly anaemic. There is a 
 rounded tumour felt in the lower part of abdomen, 
 rising out of the pelvis, about the size of a foetal head. The 
 tumour feels as though it were solid, is centrally situated, 
 and is smooth on the surface. On bimanual examination, 
 the tumour is clearly the enlarged uterus. The uterine 
 sound was not passed. 
 
 Ju/y 13, 1893.— Under ether an incision was made in the 
 middle line of abdomen, about four inches long, and com- 
 mencing just below the umbilicus. The peritoneal cavity 
 was opened along the whole length of incision in the usual 
 way. The tumour then appeared in the wound about the 
 size of a foetal head. The broad ligaments were securely 
 tied on each side with silk. Small anterior and posterior 
 flaps were then dissected from the tumour with scissors in 
 the direction of the vaginal fornices. A long Ferguson 
 speculum was introduced into the vagina and held in place 
 by an assistant and the vaginal roof opened. When the 
 uterine arteries were reached they were tied with silk in two 
 places and divided between. The vaginal fornices were 
 then cut through from above, and the whole uterus was 
 
74 
 
 removed en masse. The bleeding points in the stump 
 were tied with silk, and the ligatures, left long, were drawn 
 through the opening made in the roof of vagina. The 
 two flaps had silk ligatures passed through them from with- 
 out inwards, so that the ends of ligatures passed from the 
 raw surface over peritoneal surface. They were not tied, but 
 were also pulled through the roof of vagina, so as to turn in 
 the two peritoneal surfaces of the flaps. The vagina was 
 then packed with iodoform gauze ; a winged catheter was 
 left in the bladder. The operation lasted about an hour and 
 a half. The growth was chiefly in the anterior wall of the 
 uterus. Patient made a good recovery, and was discharged 
 August I. 
 
 Case 30. — K. F •, Eetat forty-five; admitted on 
 
 January 17, 1894, suffering from fibroid tumour of the 
 uterus, with retroflexion ; under my care. 
 
 History. — Patient has been married nine years, no children 
 or miscarriages ; has had most severe bearing-down pains 
 for the last eight or ten months. During the last two 
 months the pain has become almost unbearable. Patient 
 was in this hospital September, 1893 ; was then examined 
 under ether. The uterus was felt firmly retroflexed in the 
 pelvis ; some bosses were felt on the surface of uterus, which 
 was considerably enlarged ; the uterus could not be replaced 
 by the sound. Patient has tried various pessaries without 
 any relief ; is regular in her periods, though she has always 
 suffered much pain. Does not lose much. 
 
 January 23. — Under ether the uterus was with much 
 difficulty removed through the vagina. 
 
 January 26. — Patient doing extremely well. To be 
 syringed out every morning with iodine water through a 
 Ferguson's speculum, and a strip of iodoform gauze re- 
 placed. 
 
 February 24. — Patient discharged convalescent. 
 
 Remarks. — From a perusal of these cases it will be noticed 
 in four instances a recurrence of the disease in situ took 
 place within six months, the patients dying within the year. 
 These cases, therefore, may be said to have derived no 
 benefit from the operation, and therefore were unsuitable 
 cases for operative interference. Two cases died directly 
 from the operation. The cause of death in one case was 
 septic peritonitis, in another intestinal obstruction due to 
 
75 
 
 the omentum becoming attached to the opening in the roof 
 of the vagina. Two cases had carcinomatous deposits else- 
 where, one in the large intestine causing obstruction, and 
 the other presumably in the pylorus ; in neither of these 
 cases was there any return of the disease locally. 
 
 Three cases were free from recurrence two years after 
 operation ; in all of these the disease was apparently limited 
 to the OS and cervix uteri. One case was free from recur- 
 rence eighteen months after operation. 
 
 The lessons to be learnt by the histories of these cases is 
 the importance of early diagnosis, as if the disease has 
 extended to the broad ligaments, or into the cellular tissue 
 around the cervix, it is pretty certain to return very quickly, 
 and I would impress on all practitioners the absolute 
 necessity of vaginal examination in all cases in which a 
 patient presents herself suffering from vaginal discharge. 
 In women who have passed the menopause, should they 
 complain of haemorrhage ever so slight, or purulent dis- 
 charge, perhaps streaked with blood, it is almost certain 
 that they are suffering from malignant disease of the uterus 
 in some form or the other. The fact of the os and cervix 
 being free from any sign of ulceration is often most decep- 
 tive. But a case must never be allowed to pass if there is 
 bleeding, without a thorough examination of the uterine 
 cavity as well as the portio vaginalis. If such a plan were 
 adopted, and became a recognised rule, many a poor 
 woman's life might be saved from the horrible scourge of 
 cancer of the uterus. 
 
76 
 
 TEN CASES IN WHICH EXTENSIVE CARCINOMA OF THE 
 UTERUS WAS TREATED BY CAUSTICS. 
 
 The cases embodied under this head were all very 
 advanced cases, and all were relieved by removing the 
 disease with the dredger and caustics, as described in 
 the page 23, and were discharged in most instances with- 
 out any appreciable amount of the disease being recog- 
 nisable by most careful examination. Many of these 
 patients remained free from recurrence for some time, and 
 some are still apparently free from disease. 
 
 In two of the earlier cases the caustic ate through into 
 the rectum, and caused considerable trouble ; but in the 
 later cases, with more experience in applying the caustic, 
 this disaster has not occurred. 
 
 Uterine Dredger, 
 (a) Instrument opened, (b) Instrument closed. 
 
 The pain after the application is in nearly all cases not 
 complained of; indeed, in most cases the patients express 
 themselves the next morning as free from pain, and as 
 having been relieved of the terrible pain they had experi- 
 enced before. 
 
 All that can be claimed for this form of treatment at 
 present is that the patients' lives are prolonged, and they are 
 relieved of much suffering, and from the horrible offensive 
 discharge and bleeding. They gain flesh, and are in every 
 respect improved in health. 
 
 I am indebted to Mr. West, my house-surgeon, for the 
 notes of all these cases. 
 
 Case I. — H. M , cetat forty -six; widow, three 
 
 children, youngest twenty-three ; admitted with advanced 
 
77, 
 
 cancer of cervix uteri, on May i8, 1893, into the Cancer 
 Hospital. 
 
 May 21, 1893. — Under ether, as much disease as pos- 
 sible was scraped away with uterine dredger, and the uterine 
 cavity packed with chloride of zinc wool ; vagina packed 
 with tampons soaked in a saturated solution of bicarbonate 
 of soda. 
 
 May 23. — Tampons removed from vagina. 
 
 May 26. — Chloride of zinc wool removed. 
 . May 30. — Large slough removed. An entire cast of 
 uterus. 
 
 July I. — Patient discharged; no discharge and free from 
 pain. 
 
 Case 2. — M. T , setat sixty - four ; married, one 
 
 child; admitted on June i, 1893, into the Cancer Hospital, 
 suffering from advanced cancer of cervix uteri. 
 
 June 6. — Under ether, growth scraped with the dredger, 
 and uterus packed with chloride of zinc wool ; vagina packed 
 with tampons soaked in a saturated solution of bicarbonate 
 of soda. 
 
 June 8. — Vaginal tampons removed. 
 
 June II. — Chloride of zinc wool removed. 
 
 June 13. — Large slough removed from uterine cavity. 
 
 'June 28. — Uterus packed again with zinc chloride wool. 
 
 July I. — Zinc chloride removed. 
 
 July 3. — A slough composed of entire cast of uterus 
 removed. 
 
 July 13. — Patient discharged, very much improved; no 
 pain or discharge to speak of. 
 
 Case 3. — M. M , setat thirty-eight; married, has 
 
 had twelve children, the last child born eighteen months 
 ago; admitted on June 10, 1894, into the Cancer Hospital, 
 suffering from advanced cancer of cervix uteri. 
 
 June 17. — Growth scraped away as much as possible with 
 the uterine dredger, and uterus packed with chloride of zinc 
 wool; vagina packed with tampons soaked in a saturated 
 solution of bicarbonate of soda. 
 
 June 19. — Tampons in vagina removed. 
 
 June 20. — Chloride of zinc wool removed, and uterus well 
 syringed out through Ferguson's speculum with iodine water. 
 
 June 28. — Chloride of zinc wool again packed into uterine 
 cavity. 
 
78 
 
 July 3. — Chloride of zinc wool removed. 
 
 July 7. — Large slough removed. 
 
 July 20. — Patient discharged much improved ; very little 
 discharge or pain. 
 
 Case 4. — M. P , aetat forty-three ; married, has 
 
 had one child, twenty-three years ago \ admitted on Septem- 
 ber 20, 1893, ^ith advanced cancer of uterus. 
 
 September 25. — Under ether, disease as much as possible 
 scraped with uterine dredger, and cavity packed with some 
 freshly-prepared chloride of zinc paste. Vagina packed 
 with wool soaked in saturated solution of sodium bicar- 
 bonate. 
 
 September 30. — Zinc paste and wool removed from 
 uterus. 
 
 October 7. — Slough, comprising whole of uterus, removed 
 en 7nasse. Posterior wall of vagina also sloughed, as 
 patient had troublesome recto-vaginal fistula. Inguinal 
 colotomy performed on October 31, 1893. 
 
 December 4. — -Patient discharged ; no disease felt. 
 
 Case 5.— L. P , astat thirty-eight; married, fourteen 
 
 children, eleven living ; admitted with advanced cancer of 
 uterus on September 16, 1893. 
 
 September 26. — Under ether disease scraped with dredger, 
 and cavity packed with wool soaked in a freshly-prepared 
 paste of chloride of zinc. Vagina packed with tampons 
 soaked in a saturated solution of bicarbonate of soda. 
 
 October 1. — Zinc chloride wool removed. 
 
 October 7. — Slough, comprising whole of uterus, removed 
 en masse. 
 
 December 11, 1893. — Patient discharged; much im- 
 proved. 
 
 Case 6. — R. S , setat thirty-seven ; married, three 
 
 children, the last child born eight years ago ; admitted on 
 September 20, 1893, into the Cancer Hospital, suffering 
 with advanced carcinoma uteri. 
 
 September 26, 1894. — Disease scraped away as far as 
 possible with dredger. Uterine cavity packed with a 
 chloride of zinc paste freshly prepared. Vagina packed 
 with tampons soaked in saturated solutions of bicarbonate 
 of soda. 
 
 October 7. — Slough, comprising entire uterus and posterior 
 wall of vagina, removed efi masse. 
 
79 
 
 November 2o. — Patient discharged ; wound quite healed. 
 On making vaginal examination, the vagina is found to end 
 in a blind pouch, about an inch and a half long ; no disease 
 felt anywhere ; patient expresses herself as quite well. 
 
 Case 7. — S. B , Eetat forty -six; married, two 
 
 children, youngest twenty-one years ; admitted with ad- 
 vanced cancer of uterus on October 25, 1893. 
 
 November i, 1893. — Under ether, as much disease as 
 . possible scraped away with uterine dredger, and cavity thus 
 made packed with chloride of zinc wool. 
 
 November 5. — Zinc wool removed. 
 
 November %. — Large slough removed. 
 
 November!^. — Uterus packed again with zinc chloride wool. 
 
 November 13. — Wool removed. 
 
 November 17. — Another large slough removed. 
 
 November 23. — Patient discharged; much improved; 
 very little discharge. 
 
 Case 8. — E. M , aetat fifty - three ; married, one 
 
 child, twenty-six years ago : admitted into the Cancer 
 Hospital on January 12, 1894, suffering from advanced 
 cancer of uterus. 
 
 January 16. — Under ether, the disease as far as possible 
 was scraped away with the uterine dredger, and the cavity 
 thus made was packed with zinc chloride wool saturated in 
 freshly prepared chloride of zinc paste. The vagina was 
 packed with tampons soaked in a saturated solution of 
 bicarbonate of soda. 
 
 January 20. — Zinc wool removed ; well syringed out with 
 iodine water through Ferguson's speculum. 
 January 23. — Large slough removed. 
 
 February 22. — Patient discharged; much improved; ex- 
 presses herself as well. 
 
 Case 9. — M. C , setat fifty - four ; widow, nine 
 
 children; admitted on March 7, 1894, with advanced 
 cancer of uterus. 
 
 March 20, 1894. — Under ether, disease scraped away as 
 far as possible with dredger, and packed with chloride of 
 zinc wool. 
 
 March 25. — Chloride of zinc wool removed ; well syringed 
 with iodine water through Ferguson's speculum. 
 
 March 27.— Large slough, comprising cast of entire 
 uterus, came away. 
 
8o 
 
 April 12. — Patient discharged; has no pain or dis- 
 charge. 
 
 Case lo. — A. L , tetat forty -two; married, ten 
 
 children, one miscarriage ; admitted on March 28, 1894, 
 with advanced cancer of uterus. 
 
 April 3, 1894. — Under ether disease scraped away as far 
 as possible with the uterine dredger, and cavity packed with 
 chloride of zinc wool ; vagina packed in the usual way. 
 
 April 7. — 'Chloride of zinc wool removed ; vagina well 
 syringed out with iodine water through a Ferguson's 
 speculum. 
 
 April 9. — A large slough removed. 
 
 April 21. — Patient discharged much improved. 
 
A 
 
 CATALOGUE OF THE PUBLICATIONS 
 
 OF 
 
 BAILLIERE, TINDALL, & COX, 
 
 IN 
 
 MEDICINE, SOIEiYOE AFD ART. 
 
 CONTENTS. 
 
 PAGE 
 
 
 PERIODICAL PUBLICATIONS . 
 
 DIRECTORIES . . . . 
 
 1 Back of Title 
 
 ANATOMY 
 
 9, etc. 
 
 ART, ARTISTIC ANATOMY, ETC. 
 
 . 11, etc. 
 
 CHEMISTRY 
 
 . 14, etc. 
 
 MEDICINE, SURGERY, AND ALLIED SCIENCES 
 
 . 26, etc. 
 
 PHARMACY . . . . 
 
 . 30, etc. 
 
 students' AIDS SERIES 
 
 . 36, etc. 
 
 VETERINARY MEDICINE AND SURGERY . 
 
 . 39, etc. 
 
 white's PHYSIOLOGICAL MANIKIN 
 
 . 42 
 
 LONDON : 
 20, 21, KING WILLIAM STREET, STRAND, 
 
 [PARIS AND MADRID.] 
 
 1894. 
 
 *^* Bailliere, Tindall, and Cox have special facilities for the disposal of authors' 
 works in the United States and abroad ; being in almost daily com- 
 munication with the principal houses and agents. 
 
PERIODICAL PUBLICATIONS. 
 
 The Medical Press and Circular. Established 1838. Published 
 every Wednesday in London, Dublin, and Edinburgh. Price 
 od. ; £1 Is. per annum, post free, in advance. 
 
 Journal of the British Dental Association. A Monthly 
 
 Review of Dental Surgery. Published on the 15th of each 
 month. Price 6d., or 7s. yjer annum, post free. 
 
 The Analyst. The Ofl&cial Organ of " The Society of Public 
 Analysts." Monthly, price Is. ; 10s. 6d. per annum, paid in 
 advance. 
 
 The Veterinary Journal, and Annals of Comparative Patho- 
 logy. Monthly, price Is. 6d. ; 18s. per annum ; Postal Union 
 19s. 6d., prepaid. 
 
 The Australasian Medical Gazette. Monthly, 2s., or yearly. 
 post free, price 21s. 
 
 Indian Medico-Chirurgical Review. Monthly, is. 6d. ; yearly 
 
 subscription, 16s., post free. 
 
 Pathology. A series of illustrations of Pathological Anatomy issued 
 in monthly parts. Each part contains 4 plates in colours, with 
 accompanying descriptive text by Professors Kast, of Breslau, 
 and Rumpel, of Hamburg. The English edition revised and 
 edited by M. Armand Ruffer, M.D. Oxon. Twelve parts by 
 subscription, post free, £2 8s. Single parts, 6s. each. Single 
 plates. Is. 6d. each. 
 
 International Journal of Microscopy and Natural Science. 
 
 Edited by Mr. Alfred Allen. Price 2s. 6d. Quarterly. 
 
 Transactions of the Royal Academy of Medicine in Ireland. 
 
 Annual volumes, 14s. 
 
 Foreign postage extra. 
 
 DIRECTORIES. 
 
 The Official Register of the Royal College of Veterinary 
 
 Surgeons ; published in accordance with the Act of Parliament. 
 Price 2s. 6d., post free in the United Kingdom. 
 
 Commercial Directory for Spain, her Colonies and South America, 
 containing 500,000 Names and Addresses of the Commercial 
 Houses, Public Officers, Offices, etc., etc. Annual, price 25s. 
 
ALPHABETICAL INDEX OF AUTHORS. 
 
 PAGE 
 
 ABERCROMBIE (J.) On Tetany in Young Children 15 
 
 ADAMS (W.) Surgical Treatment of Deformities 17 
 
 ALLAN (F. y.) Aids to Sanitary Science 31 
 
 ALLAN (J. H.) Tables of Doses 25 
 
 ALLEN (Alfred) Microscopical Science 27 
 
 ALLINGHAM (H. W.) Colotomy 8 
 
 ATTENDANTS. Handbook for Attendants on the Insane 24 
 
 BAKER (Benson) How to Feed an Infant 28 
 
 BALL — Nose and Pharynx 28 
 
 BANHAM — Veterinary Posological Tables 39 
 
 BANNATYNE (A.) Aids to Pathology 29 
 
 BEACH (Fletcher) Psychological Medicine 31 
 
 BERNARD (Claude) and HUETTE'S Text -book of Operative Surgery 33 
 
 BLACK (C). Atlas of the Male Organs of Generation 10 
 
 BLACKLEY (C. H.) Hay Fever, its Causes and Treatment 22 
 
 BODDY (E. M.) History of Salt 32 
 
 Hydropathy 23 
 
 BORTfiWICK (T.) The Demography of South Australia 16 
 
 BOWDICH (Mrs.) Confidential Chats with Mothers 15 
 
 BOWLES (R. L.) On Stertor and Apoplexy 11 
 
 BOYD (Stanley) Movable Atlas of the Foot, its Bones and Muscles 21 
 
 BRAND (A. T.) Pocket Case Book 14 
 
 BROCHARD (J.) Practical Guidefor the Young Mother 28 
 
 BROWN (George) The Student's Case-book 14 
 
 Aids to Anatomy 9 
 
 Aids to Surgery , .. 33 
 
 BROWNE (Lennox) The Throat and Nose, and their Diseases 34 
 
 Movable Atlases of the Throat and Ear 10 
 
 BROWNE (W. J.) The Moon, its Influence on Weather 27 
 
 BURKE — Tropical Diseases of the Horse 39 
 
 BURTON (J. E.) Translation of Ebstein's Gout 22 
 
 CAMERON (Chas.) Microbes in Fermentation, Putrefaction, and Disease ... 13 
 
 The Cholera Microbe and How to Meet It 15 
 
 CAMERON (Sir C. A.) History of the Royal College of Surgeons in Ireland 23 
 
 CAMPBELL (C. M.) Skin Diseases of Infancy and Early Life 32 
 
 CANTLIE (Jas.) Atlas of the Hand 10 
 
 Text-book of Naked-Eye Anatomy 9 
 
 CARDWELL (B.) Translation of Hygiene of Beauty 24 
 
 CASS ELLS (J. Patterson) Deaf-mutism and the Education of the Deaf-mute 17 
 
 CHARCOT (J. M.) Bright's Disease of the Kidneys 2; 
 
 CHRISTY (T.) Dictionary of Materia Medica 25 
 
 CHURCHILL (Fleetwood) Obstetrical and Gynsecological Nursing 28 
 
 CLARKE (J. Jackson) Cancer, Sarcoma and other Morbid Growths 14 
 
 CLARKE (Percy) Medical Laws 26 
 
 CLARKE (E. H.) The Building of a Brain 13 
 
 COFFIN (R. J. Maitland) Obstetrics 28 
 
 COLE (M. J.) Modern Microscopy ... 27 
 
 COOMBE (Russell) Epitome of B. P 3C 
 
 COOPER (R. T.) On Vascular Deafness 18 
 
 COSGRAVE (C. M.) Botany, Glossary of . i^ 
 
 COTTERELL (Ed.) The Pocket Gray, or Anatomist's Vade Mecurn 9 
 
 COURTENAY (E.) Practice of Veterinary Medicine 39 
 
 COZZOIJNO (V.) The Hvgiene of the Ear 19 
 
 CROOKE (G. F.) The Pathology of Tuberculosis 16 
 
Bailliere, Tindall, and Cox's Books. 
 
 CROSS (M. J.) Modern Microscopy 27 
 
 CRUISE. (F. R.) Hydropathy 23 
 
 CULLIMORE (D. H.) Consumption as a Contagious Disease 16 
 
 The Book of Climates 16 
 
 DARLING (W.) Anatomography, or Graphic Anatomy 9 
 
 The Essentials of Anatomy 9 
 
 DAWSON (W. E.) Guide to the Examinations of the Apothecaries' Society 19 
 
 DAY (W. H.) Irritable Brain in Children 13 
 
 DENNIS (Hy. J.) Second-Grade Perspective Drawing 11 
 
 Third-Grade Perspective Drawing 12 
 
 DESSAR (L. A.) Catarrhs and Colds 14 
 
 DOLAN (T. M.) Whooping Cough, its Pathology and Treatment 35 
 
 DOWSE (T. Stretch) Apoplexy 11 
 
 Syphilis of the Brain and Spinal Cord 34 
 
 Skin Diseases from Nervous Affections 32 
 
 The Brain and the Nerves and Influenza 13 
 
 DRAGENDORFF (Prof. G. ) Plant Analysis 15 
 
 DRYSDALE (C. R.) Nature and Treatment of Syphilis 34 
 
 DRYSDALE (John) The Protoplasmic Theory of Life 34 
 
 DUDGEON (R. E.) The Sphygmograph 32 
 
 DUFFEY (G. F.) Note-taking 14 
 
 EBSTEIN (Prof.) The Treatment of Gout 22 
 
 EDWARDS (F. Swinford) Urinary Surgery 35 
 
 ERSKINE (T.) Hygiene of the Ear 19 
 
 EVANS (C.'W. De Lacy) How to Prolong Life? 18 
 
 Consumption: its Causes, Treatment, etc 16 
 
 EWART (W.) Cardiac Outlines 14 
 
 Heart-Studies, Chiefly Clinical 22 
 
 How to Feel the Pulse 32 
 
 Symptoms and Physical Signs 14 
 
 FAU (J.) Artistic Anatomy of the Human Body Ii 
 
 . Anatomy of the External Form of Man 11 
 
 FIELD (G. P.) Diseases of the Ear 18 
 
 FINNY (F. M.) Clinical Fever Chart 21 
 
 FITZGERALD (H. P.) Dictionary of British Plants and Flowers 13 
 
 FLAXMAN (J.) Elementary Anatomical Studies for Artists 11 
 
 FLEMING (G.) Text-book of Veterinary Obstetrics 39 
 
 Neumann's Parasites of Domestic Animals 39 
 
 Text-book of Veterinary Surgery , 39 
 
 Roaring in Horses 40 
 
 •- — ■— Practical Horse-Shoeing 40 
 
 — Animal Plagues, their History, Nature and Treatment 40 
 
 Contagious Diseases of Animals 40 
 
 Tuberculosis 40 
 
 Human and Animal Variolse 40 
 
 Heredity and Contagion in the Propagation of Tuberculosis 40 
 
 FORD— Ophthalmic Notes 20 
 
 FOTHERGILL (J. Milner) Chronic Bronchitis 13 
 
 The Physiological Factor in Diagnosis 17 
 
 Aids to Diagnosis 18 
 
 The Physiologist in the Household 31 
 
 Diseases of Sedentary and Advanced Life 29 
 
Bailli^re, Tindall, and Cox's Books. 3 
 
 FOTHERGILL (J. Miliicr) Aids to Rational Therapeutics 34 
 
 Vaso- Renal Changes 24 
 
 FOY (Geo.) Anesthetics : Ancient and Modern 9 
 
 FUCHS (Dr.) The Causes and Prevention of Blindness 20 
 
 GANT (F. J. ) Text-book of the Science and Practice of Surgery 33 
 
 Diseases of the Bladder, Prostate Gland, and Urethra 13 
 
 Examinations by the Conjoint Board 19 
 
 Students' Surgery 33 
 
 GARMANY (J. J.) Surgery on the Cadaver 33 
 
 GARROD (A. E.) Plandbook of IVIedical Pathology 29 
 
 GEMMELL (Wm.) Dermic Memoranda 32 
 
 GIRAUD-TEULON— Anomalies of Vision 20 
 
 GLASGOW-PATTESON (R.) Skin and Hair 32 
 
 GOODALL (E.) Microscopical Examinations of the Brain 23 
 
 GORDON (Chas. A.) Our Trip to Burmah 14 
 
 Life on the Gold Coast 8 
 
 Lessons in Military Hygiene and Surgery 23 
 
 A Manual of Sanitation 23 
 
 • Rabies and Hydrophobia 23 
 
 GORDON (T. Hurd) Aids to Practical Chemistry 36 
 
 GORE (Albert A.) Our Services Under the Crown 27 
 
 Medical History of African Campaigns 8 
 
 GOULD — Illustrated Dictionary of Medicine, Biology, etc 18 
 
 GOW(W. J.) Handbook of Medical Pathology 29 
 
 GREEN (F. W. Edridge) Memory 27 
 
 Detection of Colour Blindness.. 20 
 
 GREENWOOD (J.) Laws Affecting Medical Men 26 
 
 GREENWOOD (Major) Aids to Zoology 35 
 
 GRESS WELL (J . B. and A. G. ) Manual of Equine Medicine and other works 40 
 
 GREVILLE (H. Leicester) Student's Hand-book of Chemistry 15 
 
 GRIFFITHS (A. B.) Micro-Organisms 12 
 
 GRIFFITHS (W. H.) Text-book of Materia Medica and Pharmacy 25 
 
 — Notes for Pharmacopoeial Preparation 30 
 
 Posological Tables 3 ^ 
 
 GUBB (Alfred S.) Aids to Gynfecology 22 
 
 GUILLEMARD (F. H. H.) Endemic Heematuria 21 
 
 HAIG-BROWN— Tonsillitis 35 
 
 HALTON (R. J.) Short Lectures on Sanitary Subjects 24 
 
 HANDBOOK for Attendants on the Insane 28 
 
 HARRIS (Vincent) Manual for the Physiological Laboratory 23 
 
 HARRIS (V. D.) Kiihne's Guide to the Demonstration of Bacteria 12 
 
 HARTMANN (Prof.) On Deaf-mutism, Translation by Dr. Cassells 17 
 
 HAYNES (Stanley) Healthy Homes 24 
 
 HAZARD (W. P.) Diseases of Live Stock 41 
 
 HEIBERG (Jacob) Atlas of Cutaneous Nerve Supply 27 
 
 HEPPEL— Analytical Conic Sections .' 21 
 
 HERRINGHAM (W. P.) Handbook of Medical Pathology 29 
 
 HERSCHELL (Geo.) Indigestion 24 
 
 Heart Diagrams and Case-book 22 
 
 HEWITT (Frederic) Ansesthetics 9 
 
 HILL (J. W.) Principles and Practice of Bovine Medicine 40 
 
 Management and Diseases of the Dog 40 
 
 HIME (T. W.) Cholera: Hov/ to Prevent and Resist It 15 
 
 The Practical Guide to the Public Health Acts 3^ 
 
4 Bailliere, Tindall, and Cox's Books. 
 
 PAGE 
 
 HO ARE — Veterinary Therapeutics 40 
 
 HOGG (Jabez) The Cure of Cataract 20 
 
 The Impairment of Vision from Shock 20 
 
 Parasitic or Germ Theory of Disease 12 
 
 HOPGOOD (T. F.) Notes on Surgical Treatment 33 
 
 HORNER (Professor) On Spectacles 20 
 
 HOWAT (G. R.) How to Prevent and Treat Consumption 16 
 
 HUNTER (Ch.) Manual for Dental Laboratory 17 
 
 HUSBAND (H. Aubrey) Handbook of Forensic Medicine 21 
 
 Aids to the Analysis of Food and Drugs 21 
 
 Handbook of the Practice of Medicine 26 
 
 Student's Pocket Prescriber 31 
 
 Urine 35 
 
 HUTCHINSON (Jonathan) Aids to Ophthalmic Medicine and Surgery 20 
 
 INCE (J.) Latin Grammar of Pharmacy 30 
 
 INTERNATIONAL MEDICAL CONGRESS 24 
 
 JAMES ( Brindley ) Replies to Questions in Therapeutics 38 
 
 JAMES (M. P. ) Therapeutics of the Respiratory Passages 34 
 
 Vichv and its Therapeutical Resources 35 
 
 JENNINGS (C. E.) On Transfusion of the Blood and Saline Fluids 35 
 
 Cancer and its Complications 14 
 
 JENNINGS (Oscar) On the Cure of the Morphia Habit 27 
 
 JESSETT (F. B.) Surgical Diseases of Stomach and Intestines 8 
 
 Cancer of the Mouth and Tongue 14 
 
 JONES (H. Macnaughton) The Diseases of Women 22 
 
 Subjective Noises in the Head and Ears 18 
 
 Hints for Midwives 28 
 
 and STEWART — Handbook of Diseases of the Ear and Naso- 
 pharynx 19 
 
 JONES (H.) Guide to Sanitary Science Exams 32 
 
 JONES (T. Wharton) Blood in Inflammation 24 
 
 JUKES-BROWNE (A. J.) Palseontology (in Penning's Field Geology) 21 
 
 KAST AND RUMPEL— Illustrations of Patholoo:ical Anatomy 29 
 
 KEETLEY (C.R. B.) Guide to the Medical Profession 26 
 
 Surgery of Knee Joint 33 
 
 KENNEDY (Hy.) An Essay on Fatty Heart 22 
 
 KINGZETT (C. T.) Nature's Hygiene 23 
 
 KNIGHT (G. D.) Movable Kidney 25 
 
 KUH N E— Demonstration of Bacteria 12 
 
 LAMBERT (J.) The Germ Theory of Disease 40 
 
 LEASK (J. G.) Questions at Medical Science Examinations 20 
 
 LEDWICH (J.) Anatomy of Inguinal and Femoral Regions 9 
 
 LEONARD (H.) The Pocket Anatomist 9 
 
 Bandaging 13 
 
 Hair 22 
 
 and CHRISTY— Dictionary of Materia Medica 25 
 
 LE SUEUR — Analytical Geometry, Straight Line and Circle 21 
 
 LETHEBY(Hy.) The Sewage Question 32 
 
 LIAUTARD (A.) Animal Castration 40 
 
 Diseases of Live Stock 41 
 
 Lameness of Horses 40 
 
 Operative Veterinary Surgery 40 
 
 UTHGOW (R. A . Douglas) From Generation to Generation 22 
 
Bailli^re, Tindall, and Cox's Books. 5 
 
 PAGR 
 
 LOWNE (B. T.) Aids to Physiology 37 
 
 LUNN (C.) The Philosophy of Voice 35 
 
 Artistic Voice in Speech and Song 35 
 
 LUPTON (J. I.) Horses : Sound and Unsound 40 
 
 MACDOUGALL (A. M.) The Maybrick Case 21 
 
 MACKENZIE (Sir M.) Diseases of the Throat (in Gant's Surgery) 33 
 
 McCAW (John) Aids to the Diagnosis and Treatment of Diseases of Children 15 
 
 MADDEN (T. More) Clinical Gynjecology 22 
 
 Churchill's Obstetrical Nursing 28 
 
 MADDLCK (Distin) Stricture of the Urethra 33 
 
 MAGNE (Dr.) How to Preserve the Sight 20 
 
 MARTIN (B. R.) Diphtheria 18 
 
 MARTIN (J. W. & J.) Ambulance Work (Questions and Answers) 8 
 
 Nursing (Questions and Answers) 28 
 
 MASSE (J. N.) Text-book of Nalced-Eye Anatomy 9 
 
 McARDLE (J. S.) Notes on Materia Medica 26 
 
 McBRIDE Anatomical Outlines of the Horse 41 
 
 McLACHLAN (John) Anatomy of Surgery 33 
 
 MEARS (W. P.) Schematic Anatomy ...'. 9 
 
 MELDON (Austin) A Treatise on Gout 22 
 
 MEYRICK (J. J.) Stable Management in India 41 
 
 MILLARD (H. B.) Bright's Disease of the Kidneys 25 
 
 MILLER (B. E.) Diseases of Live Stock 41 
 
 MOLONY (M. J.) Rupture of the Perineum 32 
 
 MONIN (E.) Hygiene of Beauty 24 
 
 MOORE (E. H.) Clinical Chart for Hospital and Private Practice 34 
 
 MOORE (J. W.) Text Book of Eruptive and Continued Fevers 21 
 
 MORDHORST (Carl) Rheumatism. Its Treatment by Electric Massage ... 32 
 
 MORGAN (John) The Dangers of Chloroform and Safety of Ether 8 
 
 MORRIS (Malcolm) The Skin (in Gant's Surgery) 33 
 
 MUCKLEY (W.J.) Student's Manual of Artistic Anatomy 11 
 
 A Handbook for Painters and Art Students on the Use of Colours 16 
 
 MURRAY (R. Milne) Pregnancy 10 
 
 MURRELL (W.) Aids to Forensic Medicine and Toxicology 21 
 
 MUTER (J.) Key to Organic Materia Medica 25 
 
 Manual of Analytical Chemistry 15 
 
 NALL (S.) Aids to Obstetrics 28 
 
 NAPHEYS (G. H.) Handbook of Popular Medicine 18 
 
 Modern Therapeutics 34 
 
 NATIONAL SOCIETY FOR PREVENTION OF BLINDNESS 20 
 
 NEUMANN (L. G.) Treatise on Parasites and Parasitic Diseases of Domes- 
 ticated Animals 39 
 
 NORTON (A. T.) Text-book of Operative Surgery 33 
 
 Osteology for Students 23 
 
 Affections of the Throat and Larynx 35 
 
 Movable Atlas of the Skeleton 10 
 
 Clinical Lectures on Recent Surgery 33 
 
 OGSTON On Unrecognised Lesions of the Labyrinth 18 
 
 ORMSBY (L. H.) Deformities of the Human Body 17 
 
 Phimosis and Paraphimosis 30 
 
 PALFREY ( J. ) Atlas of the Female Organs of Generation iS 
 
 PALMER (J. F.) How to Bring up Children by Hand 28 
 
6 Bailliere, Tindall, and Cox's Books. 
 
 PAGE 
 
 PARKE (Surgeon) Climate of Africa (in CuUimore's Book of Climates) i6 
 
 PEDDIE (M.) Manual of Physics 30 
 
 PENNING (W. H.) Text-book of Field Geology 21 
 
 PENNING (W. H.) Engineering Geology 21 
 
 Notes on Nuisances, Drains, and Dwellings 24 
 
 PETTENKOFER (Von) Cholera : How to Prevent and Resist It 15 
 
 PIERSOL (G. A.) Text-book of Normal Histology 23 
 
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Bailli^re, Tindall, and Cox's Books. 7 
 
 PAGE 
 
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8 Bailli^re, Tindall, and Cox's Books. 
 
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Bailli^re, Tindall, and Cox's Books. 19 
 
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Bailli^re, Tindall, and Cox's Books. 23 
 
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Bailli^re, Tindall, and Cox's Books. 25 
 
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Bailli^re, Tindall, and Cox's Books. 29 
 
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Bailli^re, Tindall, and Cox's Books. 31 
 
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Bailliere, Tiridall, and Cox's l^ooks. 33 
 
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34 Bailliere, Tindall, and Cox's Books. 
 
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Bailli^re, Tiiidall, and Cox's Books. 35 
 
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