The criteria which should be fulfilled to rank a case of cancer of the uterus among those suitable for a vaginal hysterectomy are . The uterus must be freely movable- -i.e., the cervix should be capable of being drawn down to the vulva.
2. There should be no extension of growth beyond the limits of the cervix on to the vaginal vault.
3. The broad ligament should be free gross extension of the 4. The uterus should be of such a size as to be delivered through the vagina without mutilation or undue traction.
Ily the adoption of the abdominal route there is added to the list of operable cases those which have it limited extension of growth on to the vaginal fornices. and possibly a few with extension into the broad liga ments, but I feel that it is neither in the interests of the patient nor of the surgeon to attempt the removal of it uterus when it is as certain as can be that the line of separation must pass through instead of outside tissues already infected. It exposes the patient to a very grave immediate risk for no possible remote benefit, as experience shows that such operations are followed by death within a period as short as if they had not been touched at all. On the other hand, I feel strongly that in cases which afford even a slender chance of successful removal the patient should be given the benefit of the chance. Even on the most pessimistic calculation she obtains in return for the operative risk a prospect of freedom from recurrence for a period of anything from six months to five years, and the reasonable probability that the recurrence, if it does come, will take the form of an internal growth, and that she will be spared the misery of death from exhaustion and chronic sepsis due to a sloughing vaginal cancer, with probably a vesico-vaginal or recto-vaginal fistula.
It does not come within the scope of this volume to describe the opera tions of vaginal and abdominal hysterectomy, hut the practitioner who is called on to carry out the of cases which have been operated upon will find some hints as to treatment in the article on Operations, After-treatment of.
From time to time it will fall to the lot of the practitioner to attend an inoperable case of uterine cancer. The three main symptoms which he will have to combat are sepsis. hiemorrhage and pain. There are two main lines of treatment, the one of active interference. the other of masterly inactivity, and which of the two should be adopted in any particular case will depend partly on the condition of the patient and partly on the physician. If the growth is sloughing extensively, with copious foul discharge and probably a good deal of hiemorrhage, it is wiser to adopt active treatment, which should take the form of curetting away under antiseptic precautions all the growth which can be removed. A copious
douche is then administered and the vagina packed with iodoform gauze, wrung out of an antiseptic solution. in order to check hiemorrhage, which is usually fairly free. On the removal of the gauze a daily vaginal douche of i in 4,000 perchloride or drachm to the pint lvsol or creolin is instituted and should be kept up till the end. The result is usually very satisfactory as regards freedom from sepsis and hiumorrhage.
Some authorities prefer to use a caustic after the curetting. The actual cautery may be applied to the raw surface. Or gauze wrung out of strong formalin solution, 5o per cent. zinc chloride solution or acetone, may be packed in through a speculum against the affected area, the lower part of the vagina being protected against the caustic by packing with dry gauze. The immediate result of such cauterisation is the formation of a slough which separates in the course of a week or ten days, leaving a granu lating surface behind. The pack should he removed in twenty-four hours and a daily douche instituted. It is worth mentioning that when the growth has extended on to the recto-vaginal or vesico-vaginal septum, the slough may extend to the wall of the bladder or rectum and a vesico vaginal or recto-vaginal fistula be the result.
When there is little sloughing or sepsis, many cases get on fairly comfortably if a daily antiseptic douche is used, without any operative interference. In such cases the growth certainly appears to progress more slowly than in those in which the stimulus of active treatment with its accompanying increased blood-supply has been adopted.
For the hmorrhage, if excessive, cauterisation and packing with gauze are the best lines of treatment. For the pain morphia must be given. It is best to give it at first only at night, but as time goes on larger and more continual doses are required as a rule. Aspirin in large doses is also useful in many cases.
Treatment with X rays and radium has been tried; although there is, in my opinion, no prospect of a cure by the use of this form of treatment, there is no doubt that in many eases it relieves suffering and prolongs life. If a large fungating or sloughing growth is present, it is better to remove as much as possible with the curette before commencing radiotherapy, but in the harder and more scirrhus-like types the treatment is best insti tuted without any preliminary operation.—R. J. J.
Cancer commencing at the vulva, in the labium, clitoris, or female urethra should be removed by a free cutting extending well beyond the diseased area, after which the glands in the groin should be thoroughly dissected nut in all cases.