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.

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. Martin sews together the walls of the cavity to diminish as much as possible the raw surface. Other operators 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.

Before introducing the caustic the vagina and the vulva should be protected by thorough greasing with an ointment composed of 1 part of bicarbonate of soda to 3 parts of vaseline.

The strength of the caustic should depend somewhat upon the thickness of the tissue that separates the cavity from the peritoneum or other important structures. The thickness may be approximately determined by palpation. Usually a 100 per cent. solution of chloride of zinc may be safely employed. If the walls of the cavity appear very thin-less than a quarter of an inch-the caustic

may be reduced to a 50 per cent. solution. Small balls of cotton, about half an inch in diameter, should be saturated with the caustic and carefully packed in the cavity. The operator should be careful to remove quickly with the sponge any excess of caustic that may be expressed from the cotton. Much unnecessary pain may be experienced if the caustic comes in contact with the vagina or the vulva.

When the cavity has been filled with the cotton balls carrying the chloride of zinc, a large vaginal tampon of cotton well greased with the alkaline ointment should be placed in the vaginal vault. The packing should be removed from the vagina in forty-eight hours, and vaginal douches of bichloride of mercury, 1: 4000, should be administered.

If this operation is carefully performed, the subsequent pain is usually slight. In some cases, however, the action of the caustic may be so painful that morphine is required.

The slough from the caustic may be discharged in one piece or in shreds. It is usually separated in from five to ten days.

The subsequent treatment of the woman consists in the frequent use of cleansing vaginal douches, such as a solution of bichloride of mercury (1: 4000), carbolic acid (3 per cent. solution), permanganate of potash (10 grains to the ounce of water), and peroxide of hydrogen (1 part of the commercial peroxide to 3 or 4 parts of water).

The palliative treatment of cancer relieves the pain, the hemorrhage, and the discharge. The relief is usually immediate, and may continue throughout the disease. The hemorrhage is usually arrested for several weeks, or even for months, and the discharge is much diminished with the destruction of the necrotic cancerous mass. The progress of the disease is delayed, and life is somewhat prolonged.

CHAPTER XVII.

DISEASES OF THE BODY OF THE UTERUS.

ACUTE CORPOREAL ENDOMETRITIS.

ACUTE inflammation of the mucous membrane of the body of the uterus is called acute corporeal endometritis. The disease is usually the result of septic infection occurring at a labor or a miscarriage. Occasionally acute gonorrheal endometritis is seen, but this disease usually produces an inflammation of the mucous membrane of the cervix and the body of the uterus that is chronic or subacute from the beginning. Septic infection through. operative traumatism, through the use of the uterine sound, or through other gynecological methods of examination may, of course, result in acute endometritis.

The pathological changes that take place in an endometrium that is the seat of acute inflammation resemble those seen in acute inflammation of mucous membranes of other parts of the body. The secretion of the utricular glands becomes much increased in quantity and altered. in character, becoming purulent and sometimes containing blood.

As would be expected, whenever the inflammation is at all severe the middle or muscular coat of the uterus is involved by the process; in other words, a metritis follows and accompanies the endometritis. In puerperal metritis abscesses varying in size from a pin-head to that of a hen's egg are sometimes found in the uterine wall.

The septic infection may extend through the muscular wall of the uterus and involve the peritoneal covering, producing in this way a perimetritis.

Acute inflammation of the endometrium sometimes occurs during the course of the exanthemata. The

changes that take place in the mucous membrane of the uterus are similar to those seen in other mucous membranes during the course of these diseases. The local condition is usually limited by the duration of the general disease. It is probable that some of the cases of arrested development of the internal organs of generation, and cases of chronic tubal and ovarian disease seen in later life, may be traced to this exanthematous form of endometritis occurring during girlhood.

The symptoms of acute endometritis vary very much in severity. Dull pain in the region of the uterus, referred to the supra-pubic region and the sacrum, is usually present. Reflex disturbance of the bladder, characterized by frequent and often painful urination, may be present; and it is very probable that mild cases of endometritis have been diagnosed and treated as light attacks of cystitis. The temperature in the puerperal cases may be very high. The discharge from the cervix. is very much increased, is puriform in character, and is occasionally streaked with blood.

Digital examination shows that the external os is patulous, the cervix enlarged and soft, and the body of the uterus somewhat enlarged and tender upon pressure. This tenderness may be elicited by pressing the fundus between the vaginal finger in the anterior vaginal fornix and the abdominal hand. Examination through the speculum shows the discharge escaping from the external os. In case the cervical mucous membrane is also involved, a red area of erosion will be seen surrounding. the os.

Acute endometritis of non-puerperal origin is best treated by rest in bed, vaginal douches of hot boricacid solution (3j to a pint of water) or of bichloride of mercury (14000) at a temperature of 100° to 110°, and the continuous use of saline purgatives. Active intrauterine treatment in these cases is not necessary. When, however, the disease occurs, as it usually does from septic infection at a miscarriage or a labor