The earliest symptoms differ, depend ing upon whether the disease begins dur ing menstrual life or after the meno pause. During menstrual life every bleeding is compared with what it has been in the same woman, and arouses suspicions when intermenstrual spotting and serous discharge occur. After the menopause any serous or sanguineous discharge is considered significant. Every woman over thirty who may ex hibit any menstrual vagary or persist ent. leueorrhma is examined. Polak (New York Med. Jonr., July 19. 190:1).
Prognosis.—The only hope of a cure is to remove the cervix or uterus very soon after the commencement of the dis ease. When the vaginal walls or para metric glands become affected, a cure can no longer be expected.
Treatment.—The best treatment is an early high amputation or hysterectomy. At present hysterectomy enjoys the great est popularity, although, if cancer of the vaginal portion could more often be dis covered earlier, amputation would prob ably find a place in the treatment. When amputation is resorted to, it should in clude quite a wide collar of vaginal mu cous membrane, and should be made an inch higher than the diseased area. Were it not for the greater danger involved, abdominal hysterectomy would be pref erable to vaginal, because the pelvic glands could be enucleated in this way; but there is no hope of a permanent cure resulting when the glands have become affected.
Vaginal hysterectomy is performed somewhat differently for carcinoma than for myoma or inflammation, the differ ence being that we must remove as much of the surrounding tissue as possible for the former. The diseased tissue is cu retted away and the cervix and uterine cavity mildly cauterized. An incision is made around the cervix in the vaginal wall fully half an inch from the diseased area. After separating the bladder, push ing it high up, and opening into the peritoneal cavity both before and behind, heavy silk ligatures are placed upon the bases of the broad ligaments about half an inch from the cervix, and tied as tightly as possible, in order that the tis sue may afterward slough off. The bases of the ligaments are then cut through, and the upper portions tied. The uterus is then cut loose, the peritoneum joined with catgut to the anterior and posterior vaginal walls, the stumps united in the median line, and the corners or sides of the vaginal wound closed at the sides. The ligatures are left long, and hang out through the ununitcd centre of the vag inal wound. Sterilized iodoform gauze is packed into the wound and against the stumps and in the vagina, and left for four or five days, when it is removed and an unirritating antiseptic douche used.
The patient is kept in bed two weeks, given only water the first twenty-four hours, liquid diet during the second and third days, and very simple, mostly liquid, diet for the remainder of the first week. The ligatures will come off in two weeks if they have been tied tightly, and will bring a slough with them.
Vaginal hysterectomy with forceps dif fers from that with ligatures in the fact that long-handled hemostatic forceps are applied to the broad ligaments instead of ligatures, and are left for thirty-six or forty-eight hours, when they are re moved. A pair is placed upon the base of each broad ligament, including the sacro-uterine ligament, and after the cervix is cut loose another pair is put on the remainder of each ligament. The connective-tissue vessels are secured by lighter forceps. A gauze packing is then placed between the forceps and left for two days after the forceps are taken off. The patient suffers great discomfort until they are removed.
appear, too short in both instances, the totals will be:— Complete cure 47.0 per cent.
Mortality 4.5 per cent.
Recurrence 50.S per cent.
Comparing amputation of the cervix with total hysterectomy, it is found that in the latter the percentage of re coveries is higher, but so is the per centage of recurrences. Partial resection of the cervix by the curette or the cau tery is a better palliative than any more radical step when the parametriurn is in fected. Smirnoff (La Gynec., Feb., '96).
Series of collected cases from the large clinics in Europe showing that, among 31,482 patients suffering from cancer, the seat of the growth was the uterus in 29.5 per cent. In all cases of cancerous uterus the entire organ should be removed. Per sonal experience in 176 cases has shown that, although epithelioma tends to be limited to the vaginal portion and that glandular carcinoma shows a remarkable tendency to limitation at the internal os uteri, there are many exceptions. The tubes in all cases of cancer of the uterine body should also be removed. Again, cervical cancer in many instances extends down the vagina in an invisible form under the mucosa, without at first caus ing any perceptible infiltration or blush of color to excite suspicion. It is most necessary, therefore, to give the disease a wide berth in the vaginal side, cutting at least 2 to 2.5 centimetres away from it. If there be the slightest involvement of the bladder-wall, that organ must be opened and the healthy flaps brought to gether after excising the disease. If the rectal wall is much involved, the cellular tissue laterally is also affected.