If the only benefits that accrue from the operation are simply a short prolongation of life, and a brief interval of freedom from suffering, then the operation is too perilous, and we cannot justify ourselves in the fatal cases by stating that we have put an end to the suffering of the patient or have contributed to procure euthanasia. Pain may be alleviated and the end may be delayed by more innocent means. In spite of incessant torture many of these patients are content to linger along until they have arranged those duties which seem incumbent on them towards their families and others.
It requires hut little reflexion to recognize the incorrectness of a state ment formulated by modern surgery (Bardenhener "), that the old style of treatment (amputation of the cervix, curetting, cauterization) " is more pleasing in its execution "to the physician. Every one who still feels it his duty to practise these old procedures knows how depressing and how laborious it is, how it most severely taxes the patience of the physician to adhere to it when contrasted with an interesting, technically difficult operation, in which at least a passing glow of satisfaction is experienced at the recollection of the numerous difficulties successfully overcome. I shall leave it to the impartial reader to decide which of the two is the more " discreditable " to medical skill, the old style of treatment, as Bardenheuer thinks, or the delirious joy of a patient who has been told, after extirpation of her cancerous uterus, that she is cured (1. c., p. 39), and who finds after the lapse of a few months that the fell disease has reappeared.
The situation would of course be entirely different if total extirpation of the uterus offered the possibility of a radical cure of the disease, or if the operation were less dangerous. In the latter respect much better results are warranted by the vaginal method of extirpation of the uterus, as first proposed, or, rather, as re-introduced by Billroth and Czerny. (The operation was first done by Sauter 1822, Blundel 182S, Recamier 1829, and others).
According to a table prepared by Hahn ' in 1882, out of forty-eight cases of total extirpation per vaginam, 14 (i.e. 29.1 per cent.) died. Hegar and Kaltenbach' mention eight deaths in twenty-nine cases, a mortality of twenty-five per cent. Czerny ' found twenty-six deaths in eighty -one operations, a mortality of thirty-two per cent. Duncan (1. c.) has col lected 276 cases, showing a mortality of 28.6 per cent. Sanger' found a
similar mortality rate in 133 cases. I have myself found records of 253 cases of this kind (including six cases of my own not yet published, with one death) with fifty-nine deaths, i.e. a mortality rate of only 23.3 per cent.
These figures show that the vaginal method of extirpation of the uterus is not only far less dangerous than the operation of Freund, but also that the mortality has decreased with the increasing number of operations. This fact is made particularly noticeable from the figures published by Pfannenstiel,' who found that in 134 operations done up to 1882 the mortality rate was twenty-three per cent., whereas in thirty-six operations performed since then it had fallen to 8.3 per cent.
As a palliative procedure the operation has, therefore, a high value. Whether it is destined to afford radical relief cannot at present be decided. It would certainly seem that the majority of patients succumb sooner or later to a recurrence of the neoplasm.
Even if this operation gives results only as good as are observed in the removal of cancers elsewhere in the body, we must nevertheless welcome it as a justifiable, and possibly beneficent surgical interference.
The chief condition favorable to the performance of this operation, consists in the absence of cancerous infiltration of the vaginal walls, and the pelvic connective tissue, as well as downward mobility of the uterus.
Views still differ quite widely as to the best method of performing the operation under discussion.
Under antiseptic precautions the uterus is to be dragged down, after as much of the cancerous masses as possible has been removed, destroyed or disinfected. It is advisable to pass a stout double ligature through the cervix. This affords a good purchase on the womb, and prevents contact of the diseased tissues with the fresh wounds. The vault of the vagina is then incised, behind and in front of the cervix, and without the use of cutting instruments the uterus is severed from its anterior and posterior connections. It is then pulled downwards and the broad ligaments are step by step ligated and cut (Schroder). The ligatures of the broad ligaments are passed outwards through the incision into the fornix of the vagine. This is closed by sutures, a drainage tube is inserted, and iodoform tampons placed in the vagina. It is not necessary to discuss here the various modifications of this procedure that have been suggested by different authors.