Wallace' has reported ten cases of high amputation of the cervix for cancer, with two deaths. In two cases the disease returned within one year.
Of thirty-three cases of my own, of which I have accurate notes, three died of " sepsis " in consequence of the operation. One patient was well one year, another two years after the operation.
Total extirpation of the uterus was formerly sometimes performed after a similar plan, or at any rate operations similar to Schroder's have been thus styled. It would be superfluous for me, on this occasion, to sift all the published cases of total extirpation of the uterus for cancer. The reader will find in West's treatise' a record of twenty-five operations, of which twenty-two were fatal.
At that time no definite plan was pursued. The uterus was sometimes "peeled out" from the pelvic connective tissue, by way of the vagina; at other times the organ was first dislocated by force, or the operation was performed on uteri that were in a condition of spontaneous prolapse. Laparotomy was sometimes practised, but the method of extirpation that has so often been pursued with success for fibroid tumors, could not of course be employed in carcinoma of the uterus, for in the former case the line of division passes at the level of the internal os between the body and the cervix, the latter part being left behind. Besides the want of any satisfactory method, there remains the fact that in not a small num ber of the older reports there exist well-founded doubts as to the correct ness of the diagnosis; in short it seemed as if total extirpation of the uterus, for carcinoma affecting the lower segment, would have to be for ever excluded from the list of debatable operations.
In 1878, however, W. A. Freund' devised a method ingenious in con ception and daring in execution. As originally described it is as follows: After cutting through the anterior wall of the abdomen, and fixing the body of the uterus firmly with a loop, each broad ligament is separated into three portions by three ligatures, the last of which transfixes the vault of the vagina and the lower part of the broad ligament. After the uterus has in this manner been severed from its lateral connections in the pelvis the antegor and posterior parts of the fornix are dissected off from the uterus and are then cut through from within outwards. Through the
large gap between vagina and pelvis, which results after the uterus is removed, the ligatures are then passed so as to let their ends hang into the vagina. In this way a funnel-shaped opening is left, in which the peritoneal investments of the pelvis are in contact with one another, after which the margins of the opening are closely approximated by sutures so as to form a barrier between the vagina and the abdominal cavity. For the details and the various modifications of the operation I must refer to the previously mentioned paper of Freund and to the publications of numerous other operators.
The results of an extended trial of the operation show that it is scarcely a justifiable procedure, and can be of value only in a small minority of cases of cancer of the uterus. It soon became evident from the publica tions of Schink Linkenheld Baum,' Schroder, ° Mikulicz,' Ahlfeld,' Czerny, ' Kleinwiichter, ' Ohlshausen Bardenheuer and others that the operation was an extraordinarily dangerous one. According to Ahlfeld it resulted fatally forty-nine out of sixty-six, respectively sixty-nine times, according to Kleinwitchter seventy out of ninety-four times, and accord ing to Kaltenbach' fifty-eight out of eighty-eight times.
llegar and Kaltenbach have published a table of ninety-three cases with sixty-three deaths, a mortality of seventy-one per cent. Duncan' collected 137 cases showing a mortality of seventy-two per cent.
I have myself collected (including three unpublished cases of my own) 148 cases, with 106 deaths, a mortality of 71.6 per cent.
Now this high mortality rate would scarcely weigh in the balance, and the operation would remain one of the most brilliant achievements of operative medicine, if the few who survived its immediate effects were radically cured of their disease.. Unfortunately, however, the malady recurred in all the cases that have been reported, and terminated fatally in a more or less short space of time (Linkenfeld).