Vaginal Hysterectomy for Cancer
Boston Medical and Surgical Journal
I desire this evening to call your attention not so much to the technique of vaginal hysterectomy as to certain questions concerning the indications for this operation, the choice between total and partial extirpation of the uterus, the limitations within which total extirpation can and should be performed, and the results obtained. 1 will therefore consider these subjects in preference to those of the technique and various methods of the operation. At the very outset we are met by the question
... of the diagnosis of cancer of the uterus, and of the differentiation of the various forms of the disease in this organ. Although, in many cases it is very easy to make a diagnosis simply by gross appearances which are sulliciently familiar to ail physicians of experience, yet unfortunately when the alfection has reached a stage whore recognition is easy, it is often impossible to perform total extirpation, at least with any prospect of success ; and our whole endeavor should be therefore to seek a definite diagnosis as early as possible. In the incipient stages of malignant disease total extirpation is easy, and not very dangerous, and it gives excellent prospects of permanent recovery ; while if delayed too long, not only does the operation become far more formidable and difficult of accomplishment, but the recurrences are so frequent as to discredit all such operations.. It may be said, and by many it is claimed, that when cancer is discovered, and is limited to the cervix, a partial operation is all that is necessary, and great importance has been attached to the results of Schroeder and Ilofmeier. The statistics published by the latter show that a far larger proportion of the cases operated on by Schroeder and himself by high amputation of the cancerous cervix remained free from relapse than was the case after those operations where the whole uterus was removed, from this fact many writers have jumped at the conclusion that a partial amputation Is not only an easier and safer operation than total extirpation, but that it gives greater security against relapse. To understand this question properly, however, it is necessary to remember that the cases which Schroeder and Hofmeier treated by high amputation of the cervix were those of cancroid (epithelioma), in which the disease was entirely limited to the vaginal portion of cervix, and were therefore cases where the cancer was detected and removed at an early stage, and where it was of a nature tending to^emain longer localized. On the other hand, the cases which Schroeder and Ilofmeier operated on by total extirpation were those in which the cervix itself was involved, or where there was malignant disease of the body of the uterus ; therefore it is very evident that iu their hands the chances of relapse after total extirpation were much worse than after the high amputation of the cervix. In other words, they selected for the lighter operation cases of extremely limited and incipient disease, and in such there was, nevertheless, a very large per cent. of recurrences, that is, over fifty per cent. It seems hardly doubtful that there would be fewer recurrences if the whole uterus were removed, even in cases where the disease is merely cancroid of the vaginal portion ; and the consensus of opinion among Continental observers is now decidedly in favor of removing the whole organ whenever the diagnosis of malignant disease is clear. This view of the case I accept without hesitation. It should not be forgotten that the high amputation of the cervix is a difficult and somewhat dangerous operation, requiring a great deal of technical skill, and giving, even, iu Schroeder's hands, a mortality of some eight per cent. In any case in which this operation can be performed the total removal of the uterus can be accomplished with little additional difficulty or danger, and affords greater security against haîmorrhage as well as greater immunity from relapse. The customary classification of malignant disease of the cervix as established by Schroeder is : (1) cancroid of the vaginal portion (corresponding to what is frequently known as epithelioma) ; (2) carcinomatous nodule of the cervix ; (¡3) carcinoma of the mucous membrane of the cervix. The twenty-one specimens here presented and the preparations exhibited under the microscope show these various forms ; and it is to be remembered that it is only in the first and rarest of these three varieties that there is any claim of the efficiency of partial removal of the uterus. In both the other varieties, by common consent, total extirpation should be performed immediately on discovery of the disease, if, haply, it is not already too lato to accomplish it. It must not be forgotten that where carcinomatous disease of the cervix is present, even when the affection is limited to the vaginal portion, it is always possible that the malady also extends to the fundus ; and for this reason alone, if for no other, total extirpation is indicated in all cases.