Prophylaxis in cases of expected hemorrhage. (1) During pregnancy, exercise, baths and laxatives with light diet and avoidance of stimulants; (2) during confinement, slow delivery of the fœtus following it down with the hand on the fundus, and puncture of the membranes (in a head or breech presentation) when the os is nearly dilated, keeping the patient recumbent in bed. In some cases the writer has given 10 grains of chloride of calcium thrice daily for two weeks before delivery, and Atthill of Dublin, in cases where there had been hæmorrhage in previous confinements, gave a tablespoonful of the following mixture thrice daily: liquid ext. of ergot, 2 drachms; solution of strychniæ, I drachm; diluted hydrochloric acid, 2 drachms; infusion of ergot to make six ounces. In anæmic women the hydrochloric acid was replaced by one drachm of iron and ammonium citrate. Two measures should be adopted in every case: (1) proper management of the third stage; (2) never deliver in the absence of pains. Treatment. (1) External uterine massage. (2) Large quantities of hot water (118° F.) containing a little salt given through a double current tube passed up to the fundus. (3) Where hæmorrhage is due to retained adherent placenta or a portion of placenta and abdominal massage fails to bring it away, the attendant's hand must be introduced into the uterus; this must always be followed by a hot creolin intra-uterine douche. (4) Gauze packing of the uterus. (5) Drawing downwards the uterus with tenaculum forceps passed through the lips of the cervix, this method acts by kinking and compressing the uterine arteries. Schauta of Vienna thinks atheromatous vessels are present in the placental area in such cases, and advises laparotomy in hospital cases, and in private cases eversion of the uterus into the vagina by pressure on the fundus, so that the bleeding vessels may be caught, or an india-rubber ring or a gauze bandage fastened around the everted uterus to cut off the circulation. This pressure should not be maintained for more than six hours on account of the danger of gangrene. When the bleeding stops. the uterus may be re-inverted. (6) Injection of perchloride of iron solution, a doubtful measure and not without danger. Hæmorrhage due to lacerated wounds will be controlled by the sutures used in repairing the lacerations. In rare cases of bleeding due to the injury of a previously existing intra-uterine tumor, the tumor should be removed if possible and gauze packing introduced. After treatment. Lowering of the patient's head, subcutaneous injections of ether and strychnine, hot saline enemata and the injection into the issues under the breasts of hot saline solutions. Nourishment which can be quickly absorbed and easily digested should be freely given.

THE

AMERICAN GYNECOLOGICAL

AND

OBSTETRICAL JOURNAL.

DECEMBER, 1900.

VAGINAL VERSUS ABDOMINAL HYSTERECTOMY FOR CANCER OF THE UTERUS.*

BY H. J. BOLDT, M.D., NEW YORK.

The question proposed for discussion by the chairman of this section is both interesting and important to those engaged in our line of work. I must confess it is, in my opinion, impossible to favor the adoption of either method for all cases. The trend of opinion in Germany, and with some in the United States, is in favor of the abdominal operation in all cases. Speaking for myself I should say that only in exceptional instances should abdominal hysterectomy for cancer be performed until we are in possession of facts proving its superiority over vaginal hysterectomy in ultimate results. The reason for my opinion is based on the following facts:

Cancer of the uterus should always be divided into three varieties, according to the original anatomical site of the neoplasm: First, cancer of the infravaginal portion of the cervix; second, cancer of the supravaginal portion of the cervix; third, cancer of the uterine body.

This division is not dependent upon the histologic difference of the disease in the several uterine segments, but is due to the variation of the extension of the neoplasm to neighboring structures from the starting point.

To make this clear: We know that cancer beginning in the mucous membrane covering the vaginal portion of the cervix has a decided tendency to encroach upon the vaginal mucosa, and that the histologic

*Read before the Gynæcological Section of the New York Academy of Medicine, November 22d, 1900.

appearance of the neoplasm in both situations is similar. This mode of extension, however, is not a set rule, but the disease may extend in the form of an infiltration into the perivaginal tissue beneath the mucosa. It is necessary for one to recognize such change in order that we may proceed with the proper operation. The lymphatics are not affected until late, after the cellular tissue has been invaded, except in rare instances, and then the glands first involved the iliac glands—can usually be palpated by careful bimanual rectovaginal examination under general anesthesia.

Cancer of the supravaginal portion of the cervix has the tendency to extend into the parametria and upwards into the uterine body; whereas the mucosa covering the vaginal portion, and the vagina, are implicated very late, if at all. The iliac glands are involved more frequently and earlier than in the previous form, which is due to the earlier invasion of the cellular tissue when cancer has its origin in this segment of the cervix.

Cancer beginning in the body of the uterus not infrequently extends downwards into the cervical mucosa. In corporal cancer also, the glands are not invaded until late, but in such cases those involved are the retro-peritoneal and lumbar glands.

From post-mortem observations, it must be conceded that the bloodvesels are affected only in the late stages of cancer, and that metastases seldom occur through their medium. The lymphatics are the usual means of extension of the disease.

The variation of progress of uterine cancer at different periods of life, and under varying physiological conditions, finds an explanation in the difference in circulation, size of the vessels, and lymphatic activity. To prove this by an illustration: Consider a pregnant woman in the beginning of the thirties, with cancer of the infravaginal portion of the cervix, in contrast to a woman five or ten years past the menopause, with a similar condition of the cervix. No one could question the rapidity in the growth of the neoplasm in the young woman with enlarged vessels, increased circulation and greater lymphatic activity, compared to the slow progress of the neoplasm in the older woman with narrow vessels and impaired lymphatic activity. Provided both these cases are fit for radical operation, greater chances for immediate good results lie with vaginal hysterectomy in the case of the older woman, and since the lymphatic circulation is less active and the vessels smaller, the ultimate result is equally good.

If it is conceded that cancer progresses through the medium of the lymphatics, and this must be acquiesced in, if observations count for

anything, then vaginal hysterectomy should positively be preferred in such case as the latter.

Abundant experience has shown that the glands are not usually invaded by the disease until late; even in advanced stages of cancer of the uterus the lymphatic glands are not constantly invided by cancer elements. Numerous post-mortem examinations of women who have died of cancer have shown that the glands are free in more than 50 per cent. of the cases. Experience has also proven that recurrences after radical operation, seldom take place in the glands.

Let us consider the advantages of each form of operation:

Vaginal hysterectomy permits a smaller opening of the peritoneal cavity; it usually takes less time to perform, thus avoiding, to a greater extent, the element of shock; convalescence is much more rapid; the abdominal wound, with its occasional consequences, is avoided; the direct mortality is smaller. The objection held against the vaginal operation, that one must work in the dark, by the sense of touch, does not hold good in my experience, except in that step of the operation when the bladder is separated from the cervix, and even this work can be kept within sight to a great extent by the proper application of

retractors.

Certainly, vaginal hysterectomy for cancer has no place in surgery, if the operator adopts a technique, as it was employed in former years by many, and as it is occasionally employed now-namely, to keep so close to the uterus as to remove it only, and not extirpating any cellular tissue, with the lymphatics contained in it, I have always urged, and practised, the extirpation of the parametria, as far as possible, and in malignant disease of the vaginal portion, to also resect a large portion of the upper part of the vagina. By this procedure we remove to a great extent the cancer-conveying channels.

The advantage of abdominal hysterectomy over the vaginal operation is, that it permits the more extensive removal of the lymphatics; and of the iliac, retroperitoneal, and lumbar glands. But as we have seen, the glands are rarely affected until late, when the disease is past the boundaries of a radical operation, with the hope of achieving a good ultimate result, is is therefore a question with me whether it will give a larger percentum of permanent recoveries. Time alone will answer this.

The only cases in which the abdominal operation is indicated, with my present views, are those in whom the uterus is too large or too adherent from inflammatory processes to be removed per vaginam without

morcellation, and those which the diagnosis of glanular enlargemetn is made.

What we should strive for, to get better statistics in permanent recoveries from cancer, is to teach the profession at large the importance of an early diagnosis, and to make a positive diagnosis of every instance presenting the slightest suspicious subjective or objective symptom. Too often do we see patients treated as having some trivial trouble until the patient is past the time for a radical operation with the hope for a good future outlook.

DRAINAGE IN ABDOMINAL SURGERY.*

BY J. W. LONG, M.D., SALISBURY, N. C.,

Emeritus Professor, Diseases Women and Children, Medical College of Va.

Many of the problems involved in abdominal surgery have been settled, not always in the same way by different men it is true, but by a general consensus of opinion, the outcome of our gradually accumulated knowledge, many of the procedures practised in abdominal surgery have been agreed upon.

For instance, every surgeon agrees and insists that his hands, instruments, the field of operation, etc., must be clean, surgically clean; and it doesn't matter whether a man believes in "bugs" or not, he says "you must be clean"; nor does it matter whether he scrubs his hands till the superficial epithelium slips, dyes them and bleaches them in strong chemicals, or merely scrubs his hands and rinses them in alcohol, still he emphasizes that you must be clean. Not only is cleanliness next to godliness in surgery, it is godliness itself.

While some surgeons make a short abdominal incision and some make a long incision, all agree that the incision should be sufficiently ample to allow the operator to work easily and expeditiously.

While some surgeons employ silk ligatures and sutures within the abdomen, and others use catgut, some steam their silk fractionally, others boiled it one time only, still others do both; some sterilize their catgut by dry heat, others cumolized it; yet all maintain that whatever material is employed and by whatever process it is prepared, it must be absolutely sterile, non-irritating, easily absorbed, and the smallest size commensurate with safety.

* Read before the Southern Surgical and Gynæcological Association at Atlanta, Ga., November 13, 1900.