A Text-book of Diseases of Women

by Charles B. Penrose

Involvement of the pelvic lymphatic glands may sometimes be determined by vaginal palpation, one or more such enlarged indurated glands being felt lying posterior to the uterus. In most cases, however, glandular involvement can be determined only after the abdomen has been opened.

In general, it may be said that the operation of hysterectomy should be performed in all cases in which there is no cancerous involvement of the bladder and rectum, in which the vaginal disease may all be removed, and in which the uterus is freely movable.

In those cases in which complete removal of the disease is impossible the operation of hysterectomy should not be performed, because, cure being out of the question, the symptoms of hemorrhage, pain, and discharge may be as well relieved by less dangerous forms of palliative treatment. When the disease extends beyond the limits of the uterus, hysterectomy is much more difficult and dangerous than when the uterus is freely movable.

The remote results of hysterectomy for cancer of the cervix are poor. In the very great majority of all cases submitted to operation recurrence has taken place. It seems very probable that a few of the cases of recurrence are due to transplantation of cancer-cells into healthy tissue during the operation; but the vast majority die because all of the diseased tissues have not been or can not be removed. The hope for better results from the surgical treatment of cancer of the cervix depends, not upon improvement in the surgical technique, but upon the ability of the general practitioner to recognize the disease in its earliest stages, before inaccessible structures have been involved.

Palliative Treatment of Cancer of the Cervix.—The palliative treatment consists in removing as thoroughly as possible, with the sharp spoon-curette, scissors, or knife, all the cancerous cervix, and the maintenance of the surfaces thus exposed, as far as possible, free from septic infection.

The woman should be placed in the lithotomy position; the cervix should be exposed with the Sims speculum and, if necessary, with the lateral vaginal retractors. All vegetations and all of the degenerated cervix should then be cut away. It is usually necessary to carry the excision of tissue as high as the internal os. Bleeding during this procedure is sometimes very profuse. It diminishes, however, as the more degenerated portions of the cervix are cut away and the healthier uterine tissue is reached, and therefore it is always best to complete the operation, notwithstanding hemorrhage.

The bleeding may be controlled by packing the cavity with gauze or cotton, plain or saturated with Monsel’s solution. Moderate bleeding may be checked by packing with cotton saturated with a 5 per cent. solution of antipyrine.

In rare cases, in which the excision of tissue has been carried high up in the lateral vaginal fornices, it may be necessary to ligate the uterine arteries in order to control the hemorrhage. This may be done by passing around the vessel, close to the cervix, a curved needle carrying a heavy ligature. Bleeding from the circular artery may readily be controlled in a similar way, the ligature being passed like the first suture in trachelorrhaphy.

If the operation has been thoroughly performed, there will be left a large crater or conical cavity in the vaginal vault. This cavity may then be packed with sterile gauze, or, if there is much bleeding, with gauze saturated with Monsel’s solution. Some surgeons sew together the walls of the cavity to diminish as much as possible the raw surface. Others char the walls with the actual cautery, in order to carry the destruction of tissue still farther than has been done with the knife. If the removal with the curette and knife has been thorough, it is not necessary to make a caustic application. If, however, the cavity is walled by obviously cancerous tissue, the use of the caustic is advisable. This is usually the case.

Chloride of zinc is a valuable caustic in cancer of the cervix. It should be applied as follows: After the cancerous tissue has been removed as thoroughly as possible with the knife, the scissors, and the curette, bleeding from the walls of the cavity should be checked by packing with gauze, dry or saturated with a 5 per cent. solution of antipyrine. The bleeding may very often be checked in this way in a few minutes, and in this case the caustic may be immediately applied. In case, however, the bleeding is not so quickly controlled, the packing must be left in the cavity for twenty-four hours, at the end of which time it may be removed, without anesthesia, and the caustic application may be made.