Views also differ as to the advisability of complete closure of the vaginal wound, or of allowing the incisions to remain open. A middle course is probably the best, i.e., incomplete closure, with thorough drainage. It is very difficult to decide which one of the various operations described is indicated in a given case. If the cancerous disease has extended as far as, or beyond, the internal os, without, however, involving the pelvic areolar tissue, then the vaginal extirpation of the uterus is called for. Should the body of the uterus be so large that it is not feasible to pass it through the pelvis, Freund's operation may have to be done. But it seems advisable in all such cases to first sever the anterior and posterior connections of the uterus per vaginam, and then to remove the organ by laparotomy.
In view of the great gravity of Freund's operation, it will always have to be seriously considered, whether the uterus, even if enlarged, cannot be removed per vaginam, by cutting the broad ligaments from below with the womb in situ.
What method to choose when the cancer is still confined to the portio vaginalis cannot in the present state of our knowledge be strictly formu• lated. Intra-vaginal amputation, or total extirpation are, of course, to be weighed in the balance as to their relative dangers and possible advan tages. In a general way I favor extirpation, because it is so often hard to say how far cancerous infiltration may have crept upwards in the mucous membrane of the uterus, and because the probability of recurrence should be less in the more radical operation.
Thus, while there are but few cases of cancer of the uterus in which there is a good prospect of cure by surgical interference, and still fewer where this prospect is realized, there are many in which we are able to retard the progress of the disease and to abate some of the most painful symptoms for a long time. In all cases of epithelioma, in which the ulceration is not very extensive, and has not penetrated the vault of the vagina as far as the peritoneum, nor caused perforation, the actual cau tery should be employed to destroy the luxuriating masses as far as possi ble. In order to make the application thorough, it is always necessary to previously remove as much as possible of these masses either by the knife and scissors, or, when the proliferating tissue is soft, by Simon's sharp scoop. The cutting and scraping must be done under the guidance of the hand, after which a series of large cautery-irons is to be rapidly applied to the wound, and pressed in forcibly, so as to insure deep and thorough cauterization. This procedure is of course entirely unsuited
in the more deep-seated, true carcinomata, especially as long as these have not broken down and become ulcerated; they would, m fact, bring about the very conditions that are most to be feared in carcinoma of the uterus, namely, ulceration and decomposition, and are, indeed, not at all indicated in cases of spontaneous putrid liquefaction in dense and deeply seated carcinomata, nor in flat cancerous ulcers.
When limited, however, to their proper sphere, namely, epithelioma with crumbling papillary excrescences, the results obtained are often wonderful. Hemorrhage, discharge and not seldom pain, at all events all the symptoms consequent upon breaking down and ulceration of the epithelioma, often cease for a long time. In fact many patients think themselves cured, and it happens not infrequently that the entire opera tion-wound cicatrizes. From ten to twelve months may elapse before any symptoms due to a recurrence of the disease appear, the length of the interval usually depending upon how much it has been possible to scrape away and to destroy with the cautery. When the application has been thorough, its effects last on an average from one to six months, and the operation may be repeated several times with suitable intervals. The procedure simply anticipates as it were the natural course of the dis ease, inasmuch as the tissues, which would slowly slough away with re peated attacks of hemorrhage if the affection were let alone, are rapidly destroyed and removed, leaving a comparatively clean ulcer behind. In stead of allowing the proliferating cancer masses to undergo slow destruc tion, with symptoms which rapidly consume the strength of the patient, we secure to the latter a period of relief from the most agonizing symp toms.
The dangers of the operation are exceedingly slight. I have had but two deaths from pyfemia in the very numerous instances that have come under my personal observation. Nor have I ever had the misfortune to wound the peritoneum, for whenever I have been able to feel the perito neal investment of Douglas's while engaged in scraping out the vault of the vagina, I have desisted from applying the actual cautery, and no noteworthy reaction ever set in.