Vaginal hysterectomy for fibroids is usually performed for tumors from the size of an egg to a foetal head at term. A curved incision is made in the vaginal wall around the anterior edge of the cervix, and extending from the sides of the cervix straight out laterally for half an inch on either side. The bladder is pushed away from the uterus, and the peritoneal cavity opened, if possible, by tearing. A corresponding posterior vag inal incision is made, and the peritoneal cavity opened just behind the cervix. The bases of both broad ligaments are ligatured with strong catgut, and the uterus cut loose from the broad ligaments on either side as high as the ligatures are placed. The cervical canal is then in cised laterally and the anterior wall of the cervix amputated. The anterior uterine wall is then grasped with te naculum forceps, and a triangle is cut from its centre. Another is cut from either side extending higher up, and as tumors are encountered they are cut up and enucleated. Pretty soon the ante rior uterine wall and tumors are all moved, and the posterior wall folds upon itself, allowing the fundus and uterine appendages to be pulled down into the vagina. The remainder of the broad ligaments are now ligated, and all ine tissue cut away. The peritoneum is brought down with forceps and stitched to the vaginal walls before and behind, and then the anterior and posterior inal walls are brought together with sutures that catch and hold the stumps. Palliative treatment is mainly used for the relief of hemorrhage or pain and to check the growth of the tumors. Ergot is the most valuable palliative remedy.
Occasionally it expels polypoid and sessile tumors through the cervix. By ishing the vascularity of the uterine walls hemorrhage may be diminished and sometimes the growth of the tumors arrested. Half a drachm may be given three times daily for half or two-thirds of the time, and be continued, if neces sary, for a year or more, or off and on until the change of life. Fluid extract of hydrastis: Canadensis (V, drachm three times daily) has a slight influence of a similar character.
Electricity applied to the interior of the uterus may be made to cauterize the endometrium and thus temporarily re lieve the hemorrhage.
The electrical treatment as carried out by Apostoli's method is efficacious in about 00 per cent. of hemorrhagic fibroids. It acts favorably on the gen eral system. Pains are, in 50 per cent. of cases, relieved. In 10 per cent. the tumor is caused to disappear. Bergonie (Jour. de Med. de Bordeaux, June 20, '97).
Curettage also acts beneficially upon the endometritis, and thus upon the hemorrhage.
Ligature of the vessels supplying the uterus acts temporarily in diminishing the blood-supply to the uterus and in checking excessive hemorrhage. The anastomotic circulation, however, re stores, to a great extent, the original condition. The bases of the broad liga ments may be ligated through an in cision in the lateral vaginal fornices (Martin, Dorsett, Gottschalk), or the upper portions may be ligated through an abdominal incision (Byron Robinson).
Remote results of and the indication for vaginal ligation of the uterine ar teries in cases of myoma of the uterus: 1. Vaginal ligature of the uterine arteries in their different branches from the uterus to the point of division is an oper ation entirely devoid of danger. It is preferable to ligate in three or four stages, after the freeing of the bladder, the cervix, and the broad ligaments on each side, the ligamentum cardinale, and the base of the broad ligament, with strong silk in a Deschamps needle. This operation was well supported even by women entirely exsanguiue and ex hausted. who would assuredly succumb to radical intervention. 2. After this operation the uterus and its tumor can receive no more arterial blood save by the internal spermatic artery and by means of the artery of the round liga ment from the terminal ramifications of the epigastrie artery. 3. The nutrition of the uterus is assured after the operation. 4. The vaginal ligature of the uterine ar teries, in suitable eases, can subdue bet ter than any other palliative method the ha'morrhages of myomata, and reduce the tumors to nuclei so small that they are no longer evident in clinical examina tion. 5. But it is essential to choose cases suitable to the method. 6. The following data are snbmitted: (a) The myomata most amenable to the method were es sentially interstitial myomata developed in the inferior and middle portions of the womb, rather than those situated at the htch's. Intraligamentary tumors were altogether inadmissible. (b) The nearer the subject to the menopause, the greater the chances of a radical success by the method of ligature. (c) The method was especially applicable in those eases in which the tumor did not exceed in size a woman's head. (d) If pelvic peritonitis had preceded, it was very likely that the tumors had contracted adhesions with neighboring organs, particularly with the epiplan, and that they drew therefrom new arterial vessels which would render success doubtful. (e) Before the scrap ing of the uterine mucosa, which is al ways the first step in the operation, the uterus should be dilated with a tent in all cases in which there is reason to sus pect a myoma beneath the mucosa, since it is better to extirpate radically the myomas situated in the uterine cavity. S. Gottschalk (N. Y. Med. Jour., Aug. 25, 1900).
Carcinoma of the Uterus.
Cervix Uteri.—Carcinoma affects the cervix uteri more often than any other part of the body. It may occur at any age after puberty, but most frequently develops between the thirty-fifth and sixtieth years.
Three varieties are met with, viz.: the pavement-cell carcinoma and the ulcerating and infiltrating (nodular) forms of the cylindrical-cell carcinoma. The pavement-cell variety starts, as a rule, on the vaginal portion, and the cylindrical-cell within the cervical cav ity; but when, from laceration, erosion, or other cause, the endocervical epithe lium becomes squamous, or that of the vaginal portion becomes cylindrical in character, the place of origin may corre spondingly change.