CARCINOMA OR CANCER OF THE UTERUS.
BY W. H. BYFORD, M.D.
While it is possible that in very rare instances the scirrhous or colloid form of cancer may attack the uterus, the practitioner will seldom meet with either. I will therefore describe but two varieties—the soft or medullary, and the epithelial. Although there is much difference histologically and microscopically, they are so nearly allied in their clinical history that I feel justified in placing them together. In the clinical description of carcinoma I shall be governed more by what I have seen at the bedside than by the observation of others.
Medullary or Soft Cancer.
I use this term in a comparative sense. By it I mean a tumor caused by a carcinomatous deposit that infiltrates, enlarges, and renders more fragile than natural the parts attacked, which after a greater or less time undergo necrotic ulceration, death, or solution of the morbid growth, giving rise to extensive ulceration. I have never seen this variety convert the uterus into a tumor of encephaloid consistence. The deposit usually begins in the extremity of the cervix and extends up to the body, and without reference to the boundaries of different tissues attacks and involves the fibrous, mucous, and serous tissues, extending to any organ or substance that may be contiguous, thus infiltrating the bladder, rectum, connective tissues in the broad ligaments, and ovaries. The necrotic ulcerations of the part where the disease began, and the extension of the deposit in the more distant parts, progress simultaneously, the one diminishing while the other is increasing the bulk of the parts involved. This kind of progressive local dissemination and necrosis of cancerous matter often results in the more or less complete destruction of the uterus, bladder, and rectum.
Accompanying these morbid processes in the pelvis, cancerous cells migrate to other and distant portions of the body, creating new centres of carcinomatous disease. These multiple centres of disease are probably in all instances caused by the errant products of the pelvic disease. This view of the subject makes the general carcinomatous disease a constitutional infection, the same as the wandering cells of the chancre give rise to constitutional syphilis.
ETIOLOGY.—No one circumstance seems so intimately connected with the origin of cancer of the uterus as age, more than half the cases occurring between the fortieth and fiftieth years, 33 per cent. between the thirtieth and fortieth; this leaves only 20 per cent. for all other ages. It very seldom attacks the young under twenty-five years or the old over fifty. So far as I have been able to examine statistics, I am not sure that cancer occurs any more frequently among multipara than nullipara. The fact that the number of childbearing women far exceeds those who are not married nor fruitful is likely to mislead us in this respect. Race does not seem to afford even comparative exception. The negro and North American Indians seem to be subjects of cancer as frequently as the European races.
If there is anything in the idea of heredity as a causative influence, it must be rather through physiological similitude of children to parents than the transference of taint from the former to the latter. If cancer is a degeneration of tissues, as the effect of a law that organs in certain individuals undergo dissolution at a particular age, we can understand that the child may inherit such physiological effect from the mother. The cell-formation of the organs of the child will be capable of reaching the same period at which the disease was developed in the mother, when the normal histological changes will be interrupted and dissolution begins. In this view of the subject the child would by virtue of its organization inherit the mode of dying evinced in the mother.
Old writers, assuming that cancer was the result of a peculiar dyscrasia, described the state of general health as a causing condition. It does not seem, however, that the majority of people in whom cancer is developed exhibit any signs of ill-health until the local disease has made sufficient advance to account for their symptoms. Indeed, many present the appearance of a faultless condition of general health until the disease is discovered to have made hopeless progress. The same may be said of the local condition. It so often happens that we are assured by a patient that she had been congratulated by her friends as one especially favored by exemption from female weaknesses. I have yet to witness any evidence that chronic inflammation, congestion, or laceration of the uterus predisposes to malignant disease of any kind.
I do not mean by this to say that patients having chronic uterine ailments may not become the subjects of cancer of the uterus. There is nothing in the gross anatomy or the histological construction of cancer to indicate an analogy to inflammation. The allegation that the long-continued irritation of laceration invites a malignant deposit in the tissues involved is mere assumption, and should rank as an unproved hypothesis.
The location of the primary lesions is usually in the cervix, but occasionally it attacks other parts of the uterus, the body next in frequency to the cervix, and less commonly the fundus.
CLINICAL HISTORY.—The early stage of cancerous development is not marked by obvious symptoms. Judging from my own observation, a bloody discharge more frequently attracts the attention of the patient than any other symptom, and this does not appear until the deposit is somewhat extensive, and it indicates necrosis. The loss of blood is sometimes copious, but generally moderate in quantity. It may be intermittent or continuous. Not infrequently in menstruating women it assumes the form of menorrhagia. The next symptom generally is a discharge of ichor, usually colored, sometimes entirely clear. With the appearance of the serous discharge the cancerous odor becomes apparent and continues. These two exhausting and disgusting symptoms continue alternating with each other with the persistence of fate.
Another symptom of cancer of the uterus is pain. It is not, however, generally an early symptom. Often it is entirely absent until the disease has made great progress. When noticed early, the pain is sharp and lancinating, consisting of recurring twinges rather than of continuous pain. When it does not occur until later in the progress of the case, it is such as arises from the accompanying congestions and inflammations.
GENERAL SYMPTOMS.—No general symptoms are manifest until the disease has made considerable advance, and often not until there begin to be degenerations in the tumor. It would seem, indeed, that the growth of cancer was not a morbifacient process, and that constitutional disturbance results from the septic influence exerted by the necrosis of the tumor.
The absorption and circulation of the products of decomposition at the extremities of the tumor through the nervous centres and secreting organs soon induce nervous ailments and derange the functions of all the important vital organs. A continuance of the derangement thus inaugurated, and kept up, eventuates in fully-developed septic fever, by which the energies of the patient are exhausted. The uniformity with which septicæmia terminates the existence of these unfortunate patients renders the exceptions to the above description very rare indeed. While patients think they are being eaten up by cancer of the womb, they are really dying from slow poison caused by absorption of dead tissues.
DIAGNOSIS.—In the great majority of cases the diagnosis of cancer is easily arrived at. For reasons already stated the disease is not suspected until the deposit is extensive and obvious changes in the shape and consistence of the cervix occur. It is enlarged, very hard, and generally irregular in shape. In most instances it is very much enlarged, measuring from one to ten times its natural diameter; the tissues are devoid of elasticity; and nodosities, projections, and sulci deform the cervix in a manner and to a degree that change the shape of the organ as nothing else does. Add to this the stinking sero-sauguinolent discharge, and the diagnosis is complete. By the time these physical changes become diagnostic features of the case the uterus becomes fixed, the immobility being obviously dependent upon the extension of the deposit to the vagina, bladder, and contents of the broad ligament. The invaded tissues become as hard and unimpressible as the uterus. We could hardly mistake cancer in this stage of development for any other disease, and as the general practitioner will seldom see it before the most of these changes have occurred, the diagnosis will generally be easy. When the tissues break down to a considerable extent the ulcers, if they can be so called, are very irregular in shape, greatly excavated, have a hard, rough, granular bottom, and are not tender to the touch. Generally they bleed upon being handled. The hardness, enlargement, irregularity of shape, and fixedness are as conspicuous features during the process of destruction as they are in the stage of deposit.
The demonstrative portion of the diagnosis, however, is derived from the histology of the deposit. "Histological examination of the changed uterine tissues shows, as in every carcinoma, a stroma of small alveoli filled with polymorphous cells, generally arranged without order; sometimes those of the periphery are implanted regularly on the wall of the alveolus. The stroma composed of connective tissues frequently contain also smooth, muscular fibres."1
1 Cornil and Ranvier, translated by Shakespeare and Simes, p. 696.
PROGNOSIS.—This form of carcinoma uteri will bear no other than a desperate prognosis. I doubt whether it is ever discovered until the deposit has reached an extent locally that renders complete ablation impracticable. In addition to this consideration the malignant cells are disseminated, if not degenerated, in distant parts.
Nature in an infinitesimal number of cases institutes curative processes. These processes consist of extensive sloughing and a species of atrophy in the morbid growth. The growth ceases to enlarge, becomes smaller, and finally disappears. Very few men are lucky enough to witness the fortunate results of these processes. Art is powerless to cure, but may do much to palliate the suffering connected with the fatal march of carcinoma.
The duration of uterine cancer is greater in the old than in the young. In the former it may last several years; in the latter it often terminates fatally in a few months.
TREATMENT.—Taking the above history of the disease as true, it will not be necessary to say much about curative treatment. If we should find a case of cancer in which the cervix is not enlarged as high up as the junction of the cervix and vagina, I would advise amputation of the cervix and excavation of the uterine tissues as extensively as possible. The amputation and excavation may be performed by means of hooks and scissors, as in epithelioma. Taking the statistics of Freund's operation, as practised and modified by himself and others, as my guide, I am not disposed to sanction or advise the complete extirpation of the uterus for this form of cancer.
The subject of palliative treatment of cancer for the relief of local symptoms, and the amelioration of the general suffering caused by the septic fever, with which the patient usually dies, is more hopeful. The local symptoms requiring palliation are the sometimes disastrous hemorrhages, fetor, acridity of the sanious discharges, and pain.
The tampon made of cotton saturated with the solution of the subsulphate of iron is generally a very effectual means of treating the hemorrhages, while it also temporarily removes the fetor and acridity of the discharges. The tampon saturated with a strong solution of alum is also very effective. Frequent injections and ablutions with a weak solution of carbolic acid or permanganate of potassium will also be very useful in keeping the discharges free from odor. Much comfort may also be derived from small pellets of absorbent cotton introduced just within the vulva to absorb the discharge. Their frequent removal will of course be necessary, but they will be found to protect the external parts from excoriations that would otherwise occur. Applications of tincture of the chloride of iron or solution of hydrate of chloral carefully made to the raw surface upon the cervix very materially correct the foulness of the discharges and lessen the process of necrosis which is continually taking place.
The local and general use of anodynes is about our only means of relieving pain. They may be used locally in suppositories introduced into the rectum or vagina, or hypodermically or by the stomach in such quantities as may be required. Further detail is unnecessary in reference to the use of anodynes, as the quantity, quality, and mode of administering them will depend so much upon the urgency of the pain and the character of accompanying symptoms.
The treatment of the septicæmia is both general and local.
The general treatment consists of such measures as will sustain the vital powers. Tonics of quinine and iron are the remedies that will be of most service, and judiciously used will greatly ameliorate the symptoms of exhaustion. A very important item in the treatment of these prolonged cases of septic fever is a well-selected diet—the more nutritious and easy of digestion the better. It should consist largely of fresh mutton, beef, poultry, game, milk, and butter. The bowels will be generally troublesome in the early part of the time by constipation, and in the later by diarrhoea. For the former a diet containing fruit and coarse flour bread will often enable us to dispense with cathartics, which are generally both exhausting and annoying. For the diarrhoea opiates can be used freely, as also bismuth, pulverized charcoal, etc. etc.
But the most important as well as the most effective measure with which to combat this destructive fever is to keep the raw surface of the tumor as free as possible of necrosed material. This is done most effectively by the sharp curette or Simon's spoon. The whole of the ulcerated surface should be thoroughly scraped off with one of these instruments. The parts completely exposed by Simon's retractors should be scraped energetically until the solid tissue is reached. It should be remembered that the tissues exposed are not sound, but are cancerous deposit. The sacrifice of it, therefore, is not a matter of importance, so that the excavation if not fearlessly should be thoroughly done. An operation of this kind is attended with two dangers. One is the removing so much substance as to open the peritoneal cavity, bladder, or rectum; and the other is hemorrhage. Care will enable us to avoid the former; and, when formidable, the latter may be staunched by the astringent tampon already mentioned.
This operation is only intended as a palliative measure, and it sometimes proves remarkably beneficial. After it the patient will occasionally rally so much and become so comfortable as to indulge in the belief that she is on the road to recovery. The amelioration lasts sometimes months. It will often be profitable to repeat the scraping several times, especially if the case is advancing slowly. It will usually not only make the patient more comfortable, but greatly protract her existence.
Epithelioma of the Uterus.
This malignant disease differs in several respects from the cancer already described. The morbid cell-growth in that form of cancer takes place in the lymph-spaces of the connective tissues of the cervix and uterine body. The lymph-spaces are converted into alveoli or nests in which the cells are developed until they become greatly distended and changed in shape. The lymph-spaces thus occupied freely communicate with each other, and of course with the lymphatic vessels. Hence, the rapid dissemination of the cells locally and the ease with which they find their way to distant parts of the system.
The cells in epithelioma are developed on the free surface of the mucous membrane. From this surface the cells seldom travel to any great distance, and consequently the disease often does not become general. Epithelioma is cancer of the mucous membrane of the uterus, while the other form is interstitial cancer of the uterus. The dense mucous membrane serves as a barrier to the passage of the cells into the surrounding tissues. After the disease has existed for a long time, the surface of the mucous membrane is impaired, and it does not resist the dissemination of the cells. Then the process of cell-dissemination is a result of partial destruction of the membrane. In cancer of the uterus they are disseminated early, and possibly from the beginning, because they are generated within the lymph-spaces, with which the lymphatic vessels are continuous.
Epithelioma of the uterus very rarely assumes the form of an ulcer; generally it is a deposit upon, or growth from, the surface of the mucous membrane. The growth assumes shapes that vary with the different localities. If the extremity or external surface of the cervix is the seat of the disease, it usually projects into the vagina as a fungus which may grow large enough to fill up that cavity. Much more frequently the cervix is enlarged and is covered with a stratum of epithelial deposit very frail in texture that bleeds freely when rudely touched. This fungous growth or deposit does not affect the mobility of the uterus, even when the cervix is considerably enlarged. When the morbid deposit takes place in the cavity of the uterus, it often does not project from the os uteri to any extent, but is confined to the cavity. When the cavity is filled up by an epitheliomatous growth emanating from the entire surface of its lining membrane, we seldom see anything more than an ashy-looking substance filling up the external os uteri. Sometimes the growth covers the whole of the mucous membrane of the body and neck, including the external covering of the latter part.
CLINICAL HISTORY.—The clinical history of epithelioma is essentially the same as that of the other form of cancer, and consequently need not be given in detail. The main symptom is hemorrhage, with an abundant and stinking sanious discharge.
DIAGNOSIS.—In examining with the finger and with both hands it will be found that the uterus is movable and not much, if any, enlarged. If the case is of the ulcerated variety, the finger may not detect the lesion; if, on the contrary, there is a fungus, it will at once detect it. Should the deposit not project from the os externum, the finger may not recognize its presence. Upon exposing the cervix to view in the ulcerative variety an ulcer of a light ash-color will be seen, presenting an irregular outline slightly excavated, and if the probe is applied to it the bottom and sides of the ulcer will be found of the same firmness and consistence as the uterine tissues. It is not indurated. If a fungus exists, it can be seen and examined. When not bleeding it is also ash-colored. The consistency of the projecting mass is sometimes tolerably firm, but more frequently it is quite frail and gives way under moderate pressure. Should the deposit be inside of the uterus, the os will be slightly dilated and filled with a gray substance.
The probe will readily pass through this frail material and enter the uterine cavity. In cases presenting such an appearance the cavity is generally enlarged and filled with this fungous deposit. These facts may be ascertained by the use of the probe while the parts are exposed to view.
The microscope will verify and correct our diagnosis. For microscopic examination some substance from the surface of the ulcer or fungoid projection may be collected and submitted for inspection. The appearances are nests or spaces of greater or less size filled with epithelioid cells.
PROGNOSIS.—Without judicious treatment practised at an early period epithelioma may be said to be invariably fatal. There is, however, much promise of great amelioration in this form of disease with the present improved methods of treatment, and in some cases we may succeed in effecting a permanent cure.
TREATMENT.—The general palliative treatment is the same as that described in the other form of cancer, and need not be repeated. While I have failed to see any other than palliative effects result from amputation of the cervix and excavation of the body of the uterus in the first form of cancer described, I have seen cures of epithelioma effected by thorough extirpation of the diseased mass. One of these cures was in a case where the disease was confined to the posterior lip of the cervix; another, where the deposit apparently occupied the whole surface of the mucous membrane of the body and cavity of the cervix. In other cases I am sure the life of the patient was prolonged and her comfort greatly enhanced. I am persuaded, from a good deal of observation, that the younger the patient the more promising the result of operations. The worst and most rapidly fatal cases of epithelioma I have seen have been in patients beyond the menopause. This is contrary to what I have witnessed in the other form of cancer, as in it the younger the patient the more rapid the progress of the disease and the least beneficial the operations were.
After a trial of the several methods pursued in the removal of epithelioma, and the different instruments used for the purpose, I prefer using the scissors, aided by hooks and vulsellum, to cut away as much of the diseased tissue and the sound structure upon which it is implanted as possible, and then burn the surface with the cautery in some of its forms or the strong caustics. When the disease is confined to the cervix, the whole of the intravaginal portion should be cut away and the excising process carried as high up as possible, carefully avoiding the peritoneal cavity on the one hand and the bladder on the other. With the cervix exposed and fixed by a vulsellum, the sharp-pointed curved scissors may be insinuated beneath the external covering, and the tissues removed by pieces until the operation is completed. When the utmost attainable portion is thus removed, I prefer applying to the whole of the cut surface pellets of absorbent cotton thoroughly moistened with the solution of the pernitrate of mercury (the acid nitrate, as it was formally called), and then filling the upper part of the vagina with dry absorbent cotton, tightly packing it so as to absorb any of the free acid. This last is necessary to defend the sound parts from the superfluous cauterization which would otherwise follow. The dressing may be removed in twenty-four hours, and the whole of the surgical cavity as well as vagina washed out with pure warm water twice a day afterward. If the cavity thus formed does not fill up, and the surface assumes a malignant aspect, it should be scraped out with a view to remove its entire surface and treated again with the acid. This last operation may be repeated again and again. It will sometimes be found that the cavity will grow less after each scraping with the sharp curette, and finally fill up.
If the disease is developed in the cavity of the uterus, Simon's sharp curette should be used to scrape out and destroy the whole mucous membrane. When this is done the cavity should be carefully filled with the cotton pellets saturated with pernitrate of mercury, as recommended for the cervical operation. And this operation should be repeated also with the same thoroughness as at first as soon as evidence of a return is manifested. When the scraping and cauterizing have been beneficial the uterine cavity will become smaller, and when the discharges indicate a reproduction of the morbid deposit the surface to be operated upon will be sensibly diminished, until finally it will be apparently almost closed. I say almost, because one of my patients, while she seems to have been cured, still menstruates.
While I do not pretend that many of these cases can be thus cured, I am sure some of them can be. Hence I do not hesitate to recommend an effort to be made in all cases in which the disease has not spread to the adjoining organs or tissues. When a cure is not thus effected, such great amelioration will so often occur as to make an operation justifiable.
The hemorrhages encountered in these operations are generally unimportant, but occasionally so much blood will be lost as to require hæmostatic measures. The practitioner should therefore be supplied with an astringent tampon and use it if necessary.
If an operation for the complete extirpation of the uterus is ever justifiable for malignant disease, I think it is in this form. The operation which I think the simplest and easiest to accomplish is that performed first in this country, so far as I know, by S. C. Lane of the Medical College of the Pacific, and in Germany by Langenbeck.