A Text-book of Diseases of Women

by Charles B. Penrose

The symptoms that have just been described are those most usual in cases of cancer. It must always be remembered, however, that these symptoms vary very much in intensity or prominence and in the stage of the disease at which they appear. Sometimes acute pain, hemorrhage, and excessive discharge are present from the very beginning—even before the presence of cancer can be demonstrated without the aid of the microscope. In other cases all these symptoms may be absent until the disease is very far advanced. None of the symptoms are absolutely pathognomonic of cancer. During the menstrual life of the woman hemorrhage from the womb occurs as a symptom of a great variety of diseases; and even in the post-climacteric period, though hemorrhage should always excite alarm, yet it may be caused by a benign form of endometritis or intra-uterine growth. The pain of cancer may also characterize a variety of benign conditions; and the vaginal discharge, even when most offensive, may be simulated by that from a sloughing intra-uterine fibroid.

The symptoms, however slight, which we know may occur with cancer of the cervix should never be disregarded. Examination should be made immediately. There should be no postponement or expectant plan of treatment. If physical examination is not satisfactory in elucidating the condition, resort should be had to the microscope. If this is not conclusive, the case should be watched as long as the suspicious symptoms continue, and further frequent examinations should be made.

If this plan of treatment is followed, and if women are taught to view with distrust, and not with complacency, any irregularities of menstruation occurring near the time of the menopause, or any post-climacteric return of menstruation or of irregular bleeding, the surgeon will be able to save many women with cancer of the womb who are now doomed to horrible deaths.

Cancer of the cervix, like cancer in other parts of the body, is of variable duration. Usually from one to three years elapse between the time when the first symptoms of the disease appear and the time of death. The disease may run its course, in exceptional cases, in a few weeks; in other cases it may last as long as five years, especially if the progress is delayed by palliative treatment.

Treatment.—Complete removal of the uterus is the only curative treatment for cancer of the cervix. If the disease is seen in the earliest stages, amputation of the cervix beyond the limits of the growth seems, theoretically at least, to be a proper plan of treatment. Practically, however, the operator can never be certain that the excision is made in healthy tissue. The senses of touch and unaided sight are not capable of defining the limits of malignant infiltration. Moreover, it must be remembered that the endometrium is very often involved secondarily from a cancerous focus in the cervix. Complete removal of the uterus should therefore always be practised in all cases in which there is a possibility of removing all of the disease.

The manner of performing this operation will be described subsequently.

The cases that are not suitable for the operation of hysterectomy are those in which the disease has extended to structures that are surgically inaccessible. Such cases include those in which the bladder or the rectum are involved, those in which the vagina is extensively implicated, and those in which the disease has extended into the broad ligaments or the cellular tissue of the pelvis.

When the bladder is involved, there are dysuria, vesical pain, and tenderness on vaginal pressure upon the base of the bladder, while the urine is altered in character, containing blood, pus, and, in the later stages, broken-down necrotic tissue. Involvement of the rectum is manifest by digital examination.

When the broad ligaments are involved the uterus is held rigidly in the pelvis or is drawn to one side, and the bases of the broad ligaments, palpated through the lateral vaginal fornices, are thick and hard. When the cellular tissue of the pelvis is generally involved the whole vaginal vault feels indurated and the uterus seems fixed in the unyielding matrix.

In examining with the view of determining the practicability of hysterectomy, it is important to distinguish between cancerous and simple inflammatory involvement of the broad ligaments. The uterus may be fixed in the pelvis by inflammatory adhesions resulting from old tubal disease, and yet the cancer of the cervix may be strictly local and in a stage suitable for hysterectomy. In the simple inflammatory cases the adhesions are more attenuated, are higher in the pelvis, and lie chiefly posterior to the uterus. They are not directly continuous with the cervix. Frequently the enlarged tube and the adherent ovary may be felt. When the uterus is fixed by cancerous involvement of the broad ligament, we readily feel that it is the base of the broad ligament that is involved. The induration is broad, it is directly continuous with the induration of the cervix, and it lies to the side of the uterus.