1900 Journal of the American Medical Association (JAMA)  
In total removal of the uterus, be it by the vaginal or abdominal route, there is danger of prolapsing bowel, but by the more perfect closure of the peritoneum from above, the danger is lessened in the latter method. The abdominal incision makes a subsequent ventral hernia a possibility to be considered, but with the combination of the interrupted and the tier or layer suture and careful approximation of muscle to muscle, the danger is practically nil. Vaginal hysterectomy is an operation which
more » ... presents no special difficulties in the class of cases to which it is applicable. It is only applicable in those cases where the carcinomatous process is strictly confined to the vaginal portion of the cervix, the cervical or uterine canal, and where the uterus is freely movable. In cases where there are adhesions fixing the organ, or where there is or has been inflammation or fixation of the appendages, the abdominal operation is safer, easier and a more rational procedure. Any enlargement of the uterus vastly increases the difficulties of the operation and offers another objection to vaginal hysterectomy. The importance of early diagnosis and prompt surgical interference in carcinomatous disease of the uterus has been so repeatedly and emphatically emphasized by all writers, and the various methods and innumerable forms of technique discussed that I feel much like offering some apology for again asking your attention to the subject of carcinoma of the uterus. However, it is not so much its early diagnosis or the manifold methods of technique in vogue of which I wish to speak a few words, but the manner of its recurrence as we have but recently learned from laboratory research and clinical experience. It is well established that practically the only form of cancer which attacks the body of the uterus is the adenocarcinomatous variety. This is also of the most frequent occurrence in the cervix. The epitheliomata are usually confined to the vaginal portion of the cervix, and extend to the vaginal walls, and even when large areas become involved are less liable to give early metastasis. The epitheliomatous nodular masses occurring in the cervix-resembling in their earlier state the pathologic characteristics of the scirrhus variety common in the breast-are slow to give rise to metastasis, and offer the best chance against a recurrence after a complete extirpation of the organ. There are three modes of recurrence which are recognized by most authorities: 1, by metastasis-by far the most common-a lymphatic involvement; 2, by incomplete removal of earcinomatous areas ; 3, by infection or direct implantation of earcinomatous cells in previously healthy tissue at the time of operation. Practically I regard this latter of little account, although I take every precaution to avoid such an infection. I believe it is of vital importance to know the original seat of the malignant growth, and particularly should its pathologic variety be determined by a careful microscopic examination before operation. For, if it is found to have arisen in the cervix, and is of the adenocarcinomatous variety, we have to recall the fact that a recurrence is apt to be metastatic ; if of the portio vaginalis, a recurrence is most apt to be in the seat of the resulting scar by incomplete removal of infected areas in the vaginal walls. A few words as to what has been learned in regard to recurrence. I need say nothing further about incomplete extirpation or infection, as these subjects are easily understood and readily appreciated. Perhaps some of you may recall cases of puerperal infection through an injury to the cervix in which a rapid spread of infection has quickly given rise to a general septicemia, and in which cases the condition of the uterus and its adnexa seemed to be but slightly implicated. An instance of this occurred at the City Hospital last autumn. A young woman was admitted having a temperature of 106 F. ; and a pulse-rate of 130. She had some tenderness and enlargement of both the liver and spleen, and was treated for ten days as a typhoid with no good results from the ordinary tub baths. No history referable to a diseased uterus could be had. To settle this point, however, I was asked to see the case. I found a swollen cervix, an enlarged uterus with its normal mobility somewhat impaired, with induration in both broad ligaments. Cultures were made from the cervical canal and a streptococcus was found to be the exciting cause. An injury to the cervix by an unclean instrument, direct infection of the glands in the parametrium, and the general lymphatic infection were the successive steps. With continued rest in bed the patient's local condition entirely subsided, and excepting the result of a septic myocarditis she had quite recovered. This is not an uncommon result where abscesses do not form in the affected glands. Again the tubes or ovaries become involved by direct lymphatic infection and the body of the uterus remains free of the disease. To understand the course of such infection a knowledge of the lymphatic system must be gained. The same comprehension of this particular anatomic feature must be had to appreciate the difficulties to be overcome by the surgeon who operates for carcinoma of the uterus. I must frankly admit that we clinicians are indebted to the men who devote their time to laboratory work for the advances which we are making to-day in this field, and our ready acceptance of their results show our appreciation of the worth of such research work. I quote W. W. Russell of Johns Hopkins University : "The direction of the lymph vessels supplying the different portions of the uterus and vagina, and the position of their glands, can be separated into three distinct groups. The first group corresponds to the 'uterine vessel and its terminal branches, and supplies the upper one-third of vagina and cervix. The first glands connected with this group are found in the parametrium at the broad-ligament bases, a short distance from the cervix. They are not constant, and when present are often so small that they are frequently not discovered during operation. The most important glands belonging to this group are those lying about the iliac vessels at their dividing point. "The second group is comprised of the lymphatic vessels supplying the greater portion of the uterine body. They converge from the fundus and body, and gradually unite into two large vessels which pass outward along the upper surface of the broad ligament in close relation to the ovarian arteries. From their course it is seen that they pass between the tube and ovary. The first glands
doi:10.1001/jama.1900.24620390004001b fatcat:tyepneopwvdyxfc62twrvmegbq