cancer as any of the varieties of that malignant affection. Miller, as
quoted by West, says: "Those growths may be termed cancerous which
destroy the natural structure of all the tissues; which are
constitutional from their very commencement or become so in the natural
process of their development; and which, when once they have infected
the constitution, if extirpated, invariably return and conduct the
person who is affected by them to inevitable destruction." If we
substitute the word malignant for cancerous in the above quotation, the
definition would include sarcoma as well as carcinoma. It will be found
upon comparing sarcoma with fibrous and cancerous tumors that it
possesses clinical and histological features common to both. If it is
not indeed the result of a transition of fibrous tumors into a
malignant form of disease, it is a connecting link between fibromatous
and carcinomatous affections, and illustrates in a remarkable manner a
relationship of these two forms of growths--viz. the morbid
proliferation of the tissue resembling those of the structure in which
they originate. Sarcoma has its origin in the fibrous portion of the
connective tissue, as do many of the fibrous tumors. It consists of a
redundant proliferation of the cells of that tissue, while the fibrous
tumor is constituted of a morbid proliferation of the fibrous element
of the connective and muscular tissues. Cancer now is admitted to be an
excessive production of the cells of the epithelium; this excessive
growth of the cells inhabiting these structures, sarcomatous and
epithelial, seems to give to them respectively the feature of
malignancy. The fibrous tumor is contained in a capsule; both forms of
these malignant growths invade the tissues without any such limitation.
In this respect the two latter resemble each other and differ from the
former. In sarcoma the cells are mingled intimately with the fibres,
and are not generally contained in alveoli, or nests, as they are
sometimes called. Cancerous cells are always surrounded by alveoli.
Sarcoma in many instances resembles very closely the fibrous tumor. In
malignancy it is very much like the cancerous tumor.
CLINICAL HISTORY.--The early symptoms of sarcoma are leucorrhoea,
hemorrhage, and tumefaction. The discharge from the genital organs
resembles that of fibrous tumors. This does not generally possess an
offensive odor, but as the disease advances necrosis of the tumor
occurs to a greater or less extent, and then the smell of the discharge
comes to {272} resemble that of cancer. The necrosis does not take
place at the expense of the uterine tissues, but is a process of
disintegration going on in the growth. The ulcer resulting does not
corrode the uterus, but it eats away the tumor. It in this respect
resembles epithelial fungus. The tumor formed by the sarcomatous
deposit is sometimes polypoid, and presents the appearance of the
fibrous polypus. In other instances it resembles to the touch a
submucous fibrous tumor, and again in others it is diffusely
disseminated into the whole structure of the uterus. When thus
diffused, like cancer it invades the neighboring organs. When the tumor
projects from the inner surface of the womb, and has attained a
considerable growth, limited necrosis occurs, and sloughs of varying
size take place, and offensive sanious discharges occur very similar to
the flow observed in cancer.
The general symptoms at first are slight, consisting of obscure pelvic
pains and pressure and increased discharge. Gradually septicæmia is
developed, and this is the condition in which the patient usually dies.
DIAGNOSIS.--There is nothing in the symptoms by which we can arrive at
a correct diagnosis, as in the early periods they resemble those of
fibrous tumors so closely as to be undistinguishable from them, and in
the latter cancer neither manual nor ocular examination will give us
any more definite information. Their qualities in this respect also are
in the early stages of development those of fibrous tumors, and in the
latter of some forms of cancer. We are therefore reduced to the
evidence afforded by microscopical examination.
When the tumor is in such a position and of such a consistence that we
can remove a fragment from it, we can study its histology. There are
two varieties, as distinguished by the shape and size of the cells. One
variety is called the small-celled sarcoma, from the size of the cells;
they are round, or nearly so, in shape. The other is called the
spindle-celled sarcoma. In some specimens of this variety the cells are
much larger than others; and hence there is the large and small
spindle-celled sarcoma. The cells are different among the fibres of the
tissues affected, and in rare instances some of the cells are contained
in imperfectly-formed alveoli, in this respect showing a further
analogy to the growth in cancer.
PROGNOSIS.--The malignancy of sarcoma is now universally recognized in
the known facts of its persistency in returning when removed, and its
simultaneous existence in many organs of the body. This acquired or
innate constitutional dissemination is not constant--no more than in
cancer, perhaps less so. Hence when the size of the tumor is small and
apparently isolated there is some encouragement to attempt a cure.
The comparative prognosis is also probably better than cancer, as it
pursues a less rapid course of development, and hence the patient may
survive for a longer time.
The local dissemination of the cells cannot always be measured, and
that their dissemination into the surrounding tissues may reach much
beyond the boundaries of the apparent tumor must be regarded as an
important element in considering the subject of prognosis in connection
with treatment by ablation or cauterization. The widespread local
dissemination of the cells of this growth is doubtless an explanation
of the term at first applied to it--viz. recurrent fibroid.
{273} TREATMENT.--It will not be necessary to consume the time of the
reader by giving the treatment of sarcoma in detail, as most of it is
identical with that of Cancer, and may be found under that head. I will
only call attention to the excellent palliative effects of ergot: this
drug will often arrest, and generally modify, the hemorrhage so often
one of the most annoying symptoms. When the tumor is in a state of
progressive necrosis, protrudes like a submucous fibrous tumor, or is
pendulous, resembling the fibrous polypus, it may, by inducing
contraction of the uterus, be expelled, partially if not completely,
and thus for the time being do away with the source of sepsis. I have
in several instances been highly gratified with its effects in this
way. In one case, when the patient was so overwhelmed with symptoms of
septic fever as to cause apprehension of immediate dissolution, the
administration of ergot expelled large masses of sloughing tissue, and
so cleansed the uterus that the symptoms subsided, the patient rallied,
and lived several months in comfort. Not less than four times this
process of expulsion was successful in relieving the same patient for
long intervals: each time the medicine was administered relief was so
marked that both she and her friends anticipated recovery.
{274}
CARCINOMA OR CANCER OF THE UTERUS.
BY WILLIAM 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 {275}
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
{276} 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.
{277} 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]
[Footnote 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 {278} 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 {279}
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.