A system of practical medicine. By American authors. Vol. 4

by Unknown

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.