SUDDEN DEATH IN A CASE OF HYSTERICAL VOMITING
seemed to me that it would be best to operate and decide It during the operation whether only to perform supra-vaginal ce amputation of the cervix or complete hysterectomy. The th operation was performed on Oct. 23rd, when the patient was arg anaesthetised first with ether and afterwards with the A. C. E. ca mixture. The operation was begun as if only for the supra-tel vaginal amputation of the cervix, but it soon became clear be that the "thickening " felt to the left was due to extension of
... the cancer in that direction, and that the removal of the cervix fo: would not remove all the diseased structure. It seemed to me eq to be worth trying to get beyond this infiltration by removing fe e . the whole uterus and clamping the left attachments of it va with large pressure forceps outside the infiltration, the object va being to get the parts internal to the pressure forceps to fa slough, and so obtain a complete removal of the diseased se tissue. Pressure forceps were used to secure the broad tv ligaments on both sides, but special care was taken to place the pair on the left broad ligament beyond the infiltrated area already mentioned. No ligatures were used, nor was the opening in Douglas's pouch sutured. The vagina was packed with carbolic gauze and the patient was sent back to bed. The operation lasted an hour and a half. The gauze was removed twelve hours, and the pressure forceps forty-eight hours, after the operation. The vagina was douched with weak iodine water every four hours after the removal of the gauze for some days. A very remarkable feature in this case was the b( occurrence of haematuria soon after the operation. The fa urine was, as usual, drawn off regularly with a catheter. It vi was obviously mixed with blood, and both blood-corpuscles tl and blood-casts were to be seen on examining the deposit B from the urine under the microscope. This condition of the B -urine continued till the 28th, after which it ceased, but there Tr was some albumen in the urine till Nov. 4th, after which o: mono was found. On Nov. 6th a large cavity was to be s, seen at the top of the vagina on examination, its surface being covered by a very offensive black material. From b that date to Nov. 20th the cavity contracted very much, all f] the sloughs having come away and the surface presenting o a healthy granulating appearance. On the 28th the granup lating surface was touched with nitrate of silver. On Dec. 4th f the granulating area was only the size of a shilling and c it was again touched with nitrate of silver. The patient got t up on Nov. 21st and went home on Dec. 5th. The highest d temperature after the operation was 100'4°, and after the f fourth day it was not above normal. From Nov. 7th weak a lead lotion was substituted for the iodine water in the vaginal e douches. There was remarkably little pain after the operar tion. The growth on microscopical examination proved to be p a columnar-celled epithelioma. I have seen the patient at p the London Hospital and have examined her there many times r since the operation, the last occasion being on April 13th of this year (more than two years since the operation). There ( has never been any sign of recurrence. Her weight on Dec. lst, ( 1890, was 7st. and on April 13th, 1893, it was 7st. lOlb. , Remarks.-I have now had seven cases of total extirpation i of the uterus for cancer, with one death. The two cases just recorded are the third and fourth cases in the series. The subsequent history of the patients after this and other operations for cancer is, of course, almost as important as the immediate result of the operation. It is generally considered that an immunity from recurrence for at least two years should follow the operation to make the result really satisfactory. As my fifth, sixth and seventh cases have been within the last two years I have not thought it desirable to publish them yet. I may say, however, that the fifth case, one of primary cancer of the body of the uterus, is still quite well (more than a year since the operation) ; that the sixth case, one of cancer of the cervix extending up to the internal os uteri, is still well (eleven months since the operation); and that the seventh case, one of primary cancer of the body of the uterus, is quite well, but it is only four months since the operation. I hope to record these cases fully at a future time. The question as to whether total extirpation of the uterus or the supra-vaginal amputation of the cervix should be the usual operation for cases of cancer of the cervix suitable for radical treatment cannot yet be regarded as settled. Certainly very satisfactory results may in some cases be obtained by the supra-vaginal amputation of the cervix, and I myself recorded several such cases in a paper read before the Royal Medical and Chirurgical Society on Dec. 13th, 1892. On the other hand, it appears to be certain that in some cases, even when the disease is apparently in an early stage, and limited to the vaginal portion of the cervix, the body of the uterus may nevertheless be involved. Professor Pozzi has recorded evidence in support of this view It still, however, seems probable that this is rather an exceptional occurrence as regards early cases of cancer of the vaginal portion; but as far as it goes it is, of course, an argument in favour of extending vaginal hysterectomy to all cases suitable for operation at all, inasmuch as one cannot tell beforehand whether or not the body of the uterus has been affected in the way described by Professor Pozzi. The mortality of the two operations respectively becomes, therefore, very pertinent to the question at issue, for if it were equal complete hysterectomy would be generally preferred. At present it certainly appears to be the fact that vaginal hysterectomy is more dangerous than the supravaginal amputation of the cervix. My own experience, as far as it goes, favours this conclusion, for whilst I have had seven complete extirpations with one death, I have had twenty-two supra-vaginal amputations without any mortality.