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seen cancer of the womb in the negro woman, and I believe the experience of the profession in the South will bear me out in the assertion that it is not a rare affection. Another point: I believe it equally common in the lower and middle walks of life as in the best, and my opinion is based on clinical observation, cases of my own and those seen in consultation. In both the negro and the lower and middle walks of life, the history of these women show that they have borne more than the average number of children, a class who have usually, too, had, preceding the invasion of the disease, unusually good health. Both of these facts coincide with the history of the cases observed by Dr. Emmett.
The prominent symptom of these cases which first attracts attention is hemorrhage. It is not our purpose here, nor is it pertinent to the scope of this work, to consider the histology of cancer, but more especially its frequency as bearing upon hemorrhage, and the relief of this as one of the forms of metrorrhagia and its immediate danger to life.
Now the form in which we oftener see malignant disease of the uterus is epithelioma of the cervix, an affection local in the outset, but which, if left unattended, endangers life both from excessive hemorrhage and from septic poisoning. I would emphasize the importance of investigation, with the end of discovering, possibly, epithelial disease if the hemorrhage occur on the verge of the menopause. A case in point is the following:
Case X.—Saw Mrs. , aged 42, wife of a retail
grocer, in the summer of 1881; found her suffering from metrorrhagia and completely exsanguined. She had been in the hands of another physician for a week previous to my visit. He had done nothing for her except to give ergot internally and to tampon the vagina. The removal of the tampon was followed by very free hemorrhage. Close examination revealed that the blood came from the interior of the cervix. Three medium-sized sponge-tents were forced into the cervix without much difficulty and the tampon re-applied. The next day the tents were removed, the cervix found sufficiently dilated. With Sims' sharp curette I scraped out a point in the cervix the size of a nutmeg, which was undoubtedly incipient cancerous disease. Nitric acid (fuming) was then freely applied, and a pledget of cotton saturated with sweet oil applied over it. The hemorrhage ceased so soon as I got into healthy tissue, and did not again return. In a week the woman was able to be out of bed and to go about her usual avocations.
The average age at which this trouble begins is 43 (Emmett). Its curability is a question which is still sub judice. The day has certainly arrived when decided operative interference is considered justifiable, even though it involve so serious an operation as the removal of the uterus and its appendages by laparotomy. But nothing has as yet been accomplished which renders the prognosis other than of the gravest. We hope for the best results when we interfere in the earliest stages of the disease. The vaginal examination should be made with the utmost care, that hemorrhage may not be brought on or aggravated. The discovery of a rough, friable mass indicates epithelioma. The odor is penetrating and peculiar, so that once recognized it is ever after diagnostic.
When the diagnosis is made out there should be no delay in operating. Hemorrhage may be temporarily controlled by vaginal injections, freely impregnated with liq. ferri persulphatis. This also has another effect; it hardens and condenses the tissues of the diseased womb. It is necessary also to keep down the odor by a vaginal wash well impregnated with some good disinfectant. I know no better than the bromo-chlor. alum, as it also possesses decided astringent properties. Churchill's Iodine applied to the bleeding surface will often check the hemorrhage, but I like Battey's Solution No. 2 (iodine, § ij.; acid, carbolic, § ss.) better than any application which I have tried to control the bleeding. In past years the acid nitrate of mercury was much lauded as a local application, but it has some time since been abandoned. Let us glance for a moment at the constitutional treatment before looking minutely into the operative procedure. Prof. McGuire of this city claims to have had benefit in cancerous disease from the internal use, long continued, of the hypophosphites of lime and soda. Certainly, we have a right to expect as much good from iron and arsenic as from any other internal remedies.
Dr. Goodell says (" Lessons in Gynaecology," p. 188): "The common-sense indications are to eradicate the disease or to check the excessive serous and bloody discharge; to correct the fetor; to allay pain and to prolong life." This is to be accomplished by the removal of the cervix by the hot wire of the battery or by the " ecraseur."
Bromine as a caustic has been recommended by Drs. Routh and Wynn Williams (quoted by Sims, Amer. Jour, of Obstetrics, vol. xii. p. 452). In the article just referred to Dr. Sims advises the following method of removing the cancerous cervix, and any disease which may have extended to the cavity of the uterus: "To exsect the whole of the diseased tissue, following it up to the body of the uterus if necessary, and when all has been done that can be done by knife and scissors, then caustic strong enough to produce a slough is applied, . . . and allowed to remain there till the slough is ready to come away." But he goes on to say, eternal vigilance is necessary, and on the appearance of the slightest induration or nodule threatening a return of the disease the operation is to be repeated. The uterus is drawn down, and if the mass is friable it is scraped off with the sharp curette; if firmer, it may be cut away with the scissors. Afterwards the surface is to be carefully examined, and every trace of diseased tissue scraped off with the sharp curette, until the uterus presents to the finger the smooth, elastic feel of healthy tissue. The cavity is now filled with cotton wool, saturated in some styptic— the liq. ferri persulphatis (i pt. to 2 pts. of water), or a solution of alum (i to 12), or a solution of carbolic acid (1 to 40). It may be necessary to remove a part of the tampon in a few hours, and more may be removed the next day; but that portion which fills the upper part of the cavity is not to be removed until the fourth or fifth day. When this is removed cotton-wool, saturated with a solution of the chloride of zinc 3 v. to 1 i. of distilled water, is substituted. This produces intense pain, which must be controlled by morphia. (The reader is referred to the leading article in vol.'xii. of the Amer. Jour, of Obstetrics for valuable information on this subject by Dr. Sims.)
In the number of the above journal for March, 1884, will be found a most admirable article by Dr. Ely Van de Warker on the same subject. Dr. Van de Warker modified Dr. Sims' procedure by making two operations. He first amputates the cervix at the vaginal junction, then uses the curette, or his finger-nail, till all possible diseased tissue has been