CANCER OF THE UTERUS.—Delay in diagnosis explains the unsatisfac tory results of operative treatment in this disease. With the late attempts to bring under the notice of the profession in all European countries and in America the serious importance of an earlier recognition of the affection, and with improvements in the technique of the operation itself, already marked progress has been achieved. As in all other forms of carcinoma, the tendency towards a more radical operative treatment has been rewarded by a steadily increasing percentage of cure.
Preventive treatment is being placed upon a firm basis. Cancerous disease of the cervix being very seldom met with in virgins, Bonney and others insist upon the causal influence of a chronic inflammatory condition of the cervix so common in married women. IIence the importance of the early treatment of simple erosions and ulceration by curetting, by tracheloplasty, or by supravaginal amputation of the cervix when these do not at once heal under milder treatment. But such measures are useless when cancer has already supervened, the only resource justifiable then being a radical removal of the entire organ.
Cancer may affect either the body or, more commonly, the cervix uteri. When the practitioner meets with a case he should first of all consider the possibility of a radical operation, as affording the patient the only hope of staving off the inevitably fatal result, and if he has any doubts on the subject he will do well to avail himself of the opinion of an expert.
The present position in regard to radical operation may be summed up as follows: The first operators on cancer contented themselves with a high amputation of the cervix, which is now universally admitted to be a totally insufficient operation and to afford only the most slender prospect of permanent relief. The operation of vaginal hysterectomy was then introduced, which was attended by a very low immediate mortality in capable hands. The after-results, however, were not particularly satis factory, and although there are few operators who cannot point to cases of cancer of the uterus which still remain well years after vaginal hyster ectomy, so great an authority as Pozzi has expressed doubt as to whether any case can be regarded as permanently cured, and the majority of honest observers would confess that at the best the ultimate results are disap pointing. Things were in this condition when Wertheim, in 1906, strongly
advocated abdominal hysterectomy, which had been abandoned by all but a few operators on account of the appalling operative mortality which had attended its performance. Wertheim was able to bring forward a long series of cases with an immediate mortality of 19 per cent., and a freedom from recurrence after 3 years of about 4o per cent. These results were the more remarkable. as in his practice he operated on cases which would be regarded as much to tar gone to afford one prospect of cure by the %aginal route. The result has been to stimulate greatly the perform ance of abdominal hysterectomy for cancer of the uterus, but it is, per haps, still too early to say whether this operation offers a greatly enhanced prospect of cure to the patient suffering from uterine cancer.
At first the abdominal operation was reserved for cases which were not considered suitable for vaginal hysterectomy—i.e., for the more advanced cases -and the immediate mortality in consequence of the very severe operation necessary was very high, ranging with most operators from 200) 25 per cent. Gymecologists have now recognised that as the abdom inal operation offers an opportunity more complete removal both of the vagina, which is usually affected by direct extension of the growth, and of the connective tissues of the broad ligaments and the iliac glands, which represent the line of lymphatic extension of the cancer cells, and as at the same time it affords complete immunity from the of infecting the vaginal wound with cancer cells, advantages such as these may well be taken in die case of comparatively early cases of cancer, and afford a reasonable probability inure complete immunity from recur rence than the vaginal operation can possibly give. As the abdominal Operation in these early cases can be performed with much more ease and rapidity than in cases where extension to the vagina, broad ligament, or lymphatics has already appeared, the operative mortality is lower, and at the same time the prospect of cure is greater.