If the wound does not gradually cicatrize it may be taken for granted that the amputation has not been performed through sound tissues; on the other hand the stump quite often cicatrizes and heals over in a compara tively short space of time, and yet a recurrence follows shortly, in which event it is probable that deeply seated islets of cancer tissue, that have escaped the surgeon's knife, have sprouted outwards to the surface.
For a time the employment of the ecraseur in its various modifications (chain and wire ecraseur) was highly recommended in order to prevent free hemorrhage during the operation. But apart from its uncertain action in this respect, the instrument should be discarded because of the other well-recognized dangers that attend its application. Even in operations in which the utmost care has been exercised, and in which the uterus has not been dislocated from its normal position, the walls of the vagina and bladder and the peritoneum have in many instances been dragged into the loop and have been injured. Quite recently Atthill' reported a case of amputation with the icraseur of a cancerous cervix, the instrument also laying open Douglas's cul-de-sac. One of the chief disadvantages of the method in the operation which we are now discuss ing consists in the fact that it by no means permits of the removal of a dis eased part within well-defined limits; the wide chain or the smooth wire can never be carried so accurately along the narrow line that separates diseased from healthy tissue as can the knife, the direction of which may be varied at any moment, at the will of the operator.
The same disadvantage, although to a lesser degree, attends the em ployment of the galvano-caustic snare, which von Grunewaldt,' Spiegel berg,' L6on C. Braun, and others have so often used with success in amputating diseased cervix. This method entails little if any hemor rhage, and is therefore sometimes indispensable. Thus in some cases of cauliflower excrescence of the cervix, that form of cancer that offers rela tively the best chances for radical cure after amputation, the patients have been reduced to so great a degree of anaemia by repeated hemorrhages that any bloody operation is entirely out of the question.
Another advantage offered by this method is the cauterization of the field of operation The disadvantages are, in the first place, want of pre cision in severing the tissues on the boundary line between health and disease, and, in the second place, the laboriousness attending its use, at least in private practice and in the smaller hospitals. •
Since it seldom happens, in epithelioma of the intra-vaginal portion of the cervix, that amputation of the latter can be performed through sound tissues, attempts have repeatedly been made to thoroughly extirpate the diseased parts even when the affection extends still higher. Funnel shaped excision, after Hegar's method, sometimes suffices, as previously mentioned, for those cases in which the mucous membrane lining the cervix is diseased up to the internal os.
SchrOderb has recently devised and successfully performed a new opera tion for those cases in which the disease has already invaded the fundus of the vagina to a slight extent, while the pelvic cellular tissue is still intact. Two strong sutures (these are not always required, according to Schroder's latest statements) are passed through the lateral Walls of the fornix vaginae near the diseased parts so as to fix the latter firmly. The knife is now carried around the vagina as far as is required to sever the cancerous from the healthy tissues, cutting just deeply enough to expose the loose cellular tissue of Douglas's and of the space between the bladder and uterus. This tissue is now torn through with blunt instruments until as much as seems necessary of the lower segment of the uterus is laid bare, which is then cut away. It is then advisable, in order to prevent hemorrhage into the surrounding connective tissue, to pass all the sutures through the stump of the uterus.
This so-called " high amputation " unquestionably constitutes a decided advance in the treatment of cancer involving the lower uterine segment. The method has been widely accepted, although but little has been pub lished concerning it.
Schroder' has recorded 105 cases of this kind. Thirteen of this number died. Of the ninety-two who recovered, twenty-seven within six months showed a recurrence of the disease that proved fatal after a shorter or longer period. Concerning twenty-seven patients nothing could be learned. Thirty-eight remained well six months after the operation. Twenty-beven of this number were still well after one year, twenty-two after eighteen months. Of this number eighteen were well after two years, fifteen were still in good health after 2i years, and twelve after three years. Five certainly remained well four years after the operation. All the others were either lost sight of, or suffered a return of the disease.