Bi-manual exploration, preferably during narcosis, should not be omitted in all those cases in which operative interference is contemplated. Special attention must be paid to infiltration of the broad as well as the sacro-uterine ligaments. The mobility of the uterus, more particularly in a downward direction, must be ascertained, where total extirpation is thought of. In this connection it is well to remember that, so far as the technical difficulty of such an operation is concerned, it makes little difference whether fixation of the uterus is due to cancerous infiltration or merely to perimetritic adhesions. It is at times qaite possible to differ entiate between cancerous and inflammatory infiltrations by the above method of examination.
The now-a-days almost universally accepted view that cancer of the lower segment of the uterus is pre-eminently a local affection, which in but very few instances, and then only after a long period of existence. gives rise to metastatic deposits in distant organs, is in full accord with the experience of all times, according to which there exists no internal remedy and no medicinal procedure which is, or ever was, capable of curing cancer of the uterus. It is not necessary to adduce special evidence in support of the truth of this assertion.
Since epithelioma of the vaginal portion continues during so long a period of its existence as a mere local affection, we have reason to hope for a radical cure after removal of the morbid tissues. Therapeutists have, therefore, been constantly engaged in the study of the best ways and means for extirpating the diseiised portio vaginalis as completely as possi ble. If we are able to entirely remove the degenerated masses, or, in a word, to operate within healthy tissues, it would afford the possibility of a complete and permanent cure. And, indeed, experience teaches that this has been done.
Until very recently recourse was had again and again to caustics and to similar procedures, in the attempt to accomplish the complete destruction of the neoplastic deposits. Cures have been recorded of all of these methods, including electrolysis,' cauterizations with sulphate of zinc (Simpson), with chloride of zinc, and similar agents.
Routh' claims to have cured epithelioma of the uterus by cauterizations with solutions of bromine, others by injecting gastric juice into the sub stance of the growths. Not one, however, of these and numerous other procedures, exhibits results which can withstand tie test of strict and rigorous criticism, and I will, therefore, only mention them further on, in so far as they have any value as palliative measures.
Actual, unquestionable cures can be and have been observed only when the attempt is successful to completely remove through healthy tissues the degenerated masses in the beginning of the disease. The following
comprises all the cases that I have been able to collect of radical cure after amputation of a cancerous vaginal portion. One of J. Simpson's' patients was well fifteen years after the operation, and had given birth to five children during the interval. The cancerous nature of the extirpated masses was verified by Goodsir.' A second patient died four years after the operation of cancer of the peritoneum; this case may perhaps be classed as cured, in so far, at least, as there was no recurrence of the dis ease in loco. A third patient succumbed also four years after operation, to dysentery.
Milischik,' removed the diseased lower segment of the uterus, the patient dying ten years later of cancer of the stomach. Zienissen's patient died of pulmonary tuberculosis seventeen years after the removal of an epithelioma of the anterior lip of the os. Other cases are recorded by C. Mayer, Martin,' and Grfinewaldt.' The last-mentioned states that he saw his patients alive and free from any recurrence of the disease five, ten, and twelve years respectively after the operation. C. Braun al ludes to a case operated upon by Schuh, where twenty years later no re turn of the disease was seen. Hegar's' patient was in good health three and a half years after amputation. amputated the cervix with the kronur for epithelioma, and some time afterwards destroyed two local recurrences with chromic acid. Four years later the patient was seen in perfect health, having given birth to a living child in the in terim.
Other similar reports may be found recorded in literature, but they do not deserve as much credence as the foregoing, partly because the period of observation after operation was too short, and partly because the diagnosis does not appear to have been above doubt. The latter is particularly true of the cases of Osiander, Lisfrauc, Dupuytren and others, who, as is well known, not infrequently mistook simple hyper trophy of the portio iginalis for carcinoma.' C. Braun' has very frequently performed this operation. Pawlick' states that Braun operated upon 136 cases, of which number 10 diet' and 16 received no benefit. Of the 110 immediate recoveries, 32 died after wards (but only 16 of actual recurrence of the disease), and concerning 22 there is no subsequent history. In 22 others the disease returned (once after nineteen mouths, and once after six years). Thirty-three patients remained well for from one to nineteen and a half years. In thirty-nine of these cases Douglas's pouch was opened during the opera tion. None of the women gave birth to a viable child after the operation. When pregnancy occurred, it was invariably followed by abortion.