Fig. 111.—Congenital erosion of the cervix.
Fig. 111.—Congenital erosion of the cervix.
Fig. 111represents the appearance of the cervix in a case of marked congenital erosion in a virtuous single woman twenty years of age. It will be observed that the appearanceresembles somewhat that seen in a bilateral laceration of the cervix with eversion. The following are the points of difference:
Inlaceration—
There is a history of previous pregnancy.
The presenting face of the cervix is oval, with the long axis antero-posterior.
The angles of laceration may be determined, by sight or touch, either as more or less well-marked depressions or as hard plugs in case they are filled up by scar-tissue. The mucous membrane of the cervical canal may be made out as a strip on the anterior and posterior lips, from which there extends laterally a more or less well-marked erosion.
The vaginal cervix is not of the general mushroom shape seen in the figure.
If microscopic examination of the cervix be made, racemose glands will be found discharging only on the mucous membrane of the cervical canal—not all over the vaginal aspect.
In thecongenital ectropion—
There may be no history of pregnancy.
The presenting face of the cervix is approximately circular.
There is no angle of laceration determined by sight or touch.
The erosion may extend evenly around the external os, and there is no one strip that corresponds to the exposed mucous membrane of the cervical canal.
The vaginal cervix is mushroom-shaped, with a decided stalk.
Microscopic examination reveals racemose glands discharging over the greater part of the vaginal cervix, to the sides of the external os, as well as in front of and behind it.
The ultimate test of this condition is the discovery of the glands discharging on the vaginal aspect of a cervix in which the mucous membrane of the cervical canal had not been exposed by laceration.
The treatment of congenital erosion of the cervix, when it is so marked as to produce distinct symptoms, is amputation of the cervix.
Congenital Split of the Cervix.—There is sometimes found a congenital split of the cervix, closely resembling a unilateral or bilateral laceration following labor or miscarriage. The recognition of this fact is of great medico-legal importance. One of the most positive signs of a former conception is a laceration of the cervix. In some cases, however, a condition resembling such a laceration may exist from birth. Marked lateral split of the cervix has been discovered in the new-born infant, and several cases have been observed in which this condition has been found in adults of undoubted virginity.
It is possible that this condition may become pathological. Cervical catarrh might be produced from exposure of the mucous membrane of the cervical canal. The lesion, however, is not of nearly such serious moment as a laceration after miscarriage or labor, for the last injury occurs in a uterus which must undergo involution, and the chief symptoms of laceration of the cervix are usually those incident to arrested involution.
Cervical Polypi.—Polypoid tumors are found growing from the mucous membrane of the cervical canal, projecting into the canal or protruding from the external os. The mucous polypus is the most usual form, and is caused by cystic degeneration of the Nabothian glands of the cervical mucous membrane. Sometimes such polypi protrude from the ostium vaginæ. Less often a papillary or warty growth is found on the mucous membrane of the cervical canal, in the neighborhood of the external os. There is usually present dilatation of the external os and cervical canal. The symptoms of cervical polypi are not characteristic. Inflammation of the cervical mucous membrane and cervical catarrh may result. There may be slight, and rarely profuse, bleeding from the external os. The bleeding may follow efforts at straining, sexual connection, long standing, or exercise. Occurring at the time of the menopause or later, this symptom would excite the suspicion of beginning cancer of the cervix.
Pediculated polypi should be twisted or cut away. Bleeding is usually very slight. The sessile growths, like the papillomata, should be excised, the incision being carried well below the base of the tumor into the healthy tissue of the cervix. The wound may then be closed with an interrupted suture. In every case of such tumor a careful microscopical examination should be made to determine its benign or malignant character.
Hypertrophic Elongation of the Vaginal Cervix.—Inthis condition there is a marked increase in the length of the vaginal portion of the cervix uteri, though the thickness of the cervix may be but little, if any, greater than normal. The vaginal cervix may be so long that the external os may lie outside the ostium vaginæ.
Fig. 112.—Mucous polyp of cervix.
Fig. 112.—Mucous polyp of cervix.
Fig. 113.—Cervical polyp.
Fig. 113.—Cervical polyp.
The condition is a true hypertrophic growth, the cause of which is unknown. It is probably congenital, as it is found in the virgin.
The diagnosis between elongation of the vaginal cervix and the various forms of prolapse of the uterus and thevagina may be readily made. In elongation of the vaginal cervix the fundus uteri is at the normal level; there is no inversion of the vagina; the vaginal fornices are in the normal position.
Elongation of the vaginal cervix to a degree sufficient to be considered pathological is very rare.
The treatment consists in amputation of the cervix.
Chancre of the Cervix.—Chancre of the cervix is a rare lesion. One observer, Rassennone, found 117 uterine chancres in a series of 1375 cases of venereal sores on the female genitals. The sore may occur on either lip of the cervix and may extend into the cervical canal. The appearance is that characteristic of similar sores in other parts of the body.
The diagnosis may be made from a history of coitus with a man having active syphilis, by microscopic examination if necessary, and by the later appearance of secondary syphilitic symptoms.
Tuberculosis of the Cervix.—Tuberculosis of the cervix is a very rare condition. The appearance of the cervix in such cases resembles that of cancer. In fact, hysterectomy has been performed for this condition under the mistaken diagnosis of malignant disease.
The diagnosis may be made by the microscopic examination of the discharge and of excised tissue.
Complete hysterectomy should be performed for tuberculosis of the cervix.
Cancer of the cervix uteri is a very common disease. About one-third of all cases of cancer in women affect the uterus. Like cancer in other parts of the body, the disease has been observed at almost every period of life except infancy. It occurs most frequently during the active mature life of the woman, between the ages of thirty and fifty. It is probable that more cases occur during the latter decade of this period than during the former.
Cancer of the cervix is a disease of the childbearing woman. It is very rare in women who have never conceived. Statistics show that women who develop cancer of the cervix have borne on an average five children. The stout, well-nourished mother of a large family is very prone to cancer of the cervix.
It is probable that the chief predisposing cause of cancer of the cervix is a fissure or laceration caused by miscarriage or labor. A focus of irritation, an area of diminished resistance, is thus developed, where cancer may start in a woman predisposed to this disease. In some of the cases of cancer of the cervix occurring in sterile women it has been found that previous traumatism had been inflicted by dilatation or incision of the cervix.
Cancer of the cervix uteri originates in one of three structures: I. The squamous epithelium covering the vaginal aspect of the cervix; II. The cylindrical cells lining the cervical canal; III. The epithelial cells of the cervical glands. The first variety is called squamous-cell carcinoma of the cervix. The second and third varieties are called adeno-carcinoma of the cervix.
The early appearance of the disease, the gross form assumed by the cancer, the direction of growth, and the clinical course depend upon the place of origin. In the late stages of the disease, characterized by extensive destruction of tissue, all forms appear alike.
I. Cancer of the vaginal aspect of the cervix (squamous-cell carcinoma) very often begins in a benign erosion of an old laceration. The early stages of transition from the benign to the malignant condition are not apparent to the unaided senses, and can be recognized only by the microscope. Later a superficial ulceration is developed, or the cancer may assume the polypoid or vegetating form, and become readily recognized by the unaided senses.
Fig. 114.—Cancer of the vaginal aspect of the cervix.
Fig. 114.—Cancer of the vaginal aspect of the cervix.
It will be remembered that true ulceration as a benign condition is very rare on the cervix uteri. The erosion of a laceration is in no sense an ulceration. An ulceration of the cervix, therefore, should always excite the gravest suspicion. The polypoid or vegetating growths vary very much in size. They are sometimes very exuberant,forming large cauliflower-like masses filling the upper part of the vagina (Fig. 114). In other cases they are small warty growths or rounded protuberances about the size of a pea. The disease usually spreads to the mucous membrane of the vagina. Less often it extends to the cervical canal and to the body of the uterus.
II. When the cancer begins in the mucous membrane of the cervical canal (adeno-carcinoma), extensive destruction of tissue may take place before any appearance of the disease is observed at the external os (Fig. 115). This is most likely to occur in those cases in which there is not present a bilateral laceration of the cervix with eversion of the mucous membrane. In some cases the whole of the cervix is destroyed, leaving only a shell, the lower portion of which is the vaginal aspect of the cervix.
Fig. 115.—Cancer of the cervical canal, with metastasis to the vagina.
Fig. 115.—Cancer of the cervical canal, with metastasis to the vagina.
When the cervix is lacerated and the mucous membrane of the canal is exposed, the disease is more early apparent, and we may then observe the malignant ulcerationof the exposed mucous membrane or the presence on it of cancerous outgrowths. This form of cancer of the cervix uteri is more likely to extend upward to the endometrium than is the form first described.
III. When the cancer begins in the distal ends of the cervical glands (adeno-carcinoma), it may appear as a nodule in the body of the cervix. It will be remembered that sometimes these glands become so distended peripherally that they appear beneath the mucous membrane of the vaginal aspect of the cervix as Nabothian cysts. In a similar way, when the glands become seats of cancerous infection, hard nodules of various size may appear or be felt beneath the vaginal mucous membrane. In other cases the nodule is situated beneath the mucous membrane of the cervical canal. These nodules disintegrate and perforate the overlying mucous membrane, and in this way form a malignant ulcer which may appear either in the cervical canal or on the vaginal aspect of the cervix.
Fig. 116.—Nodular cancer of the neck of the uterus (a) (Ruge and Veit).
Fig. 116.—Nodular cancer of the neck of the uterus (a) (Ruge and Veit).
As has been said, when ulceration and destruction takeplace, in the last stages of the disease, all the varieties of cancer present a similar appearance and are accompanied by similar symptoms.
Cancer of the cervix uteri may extend to the vagina, to the body of the uterus, to the broad ligaments, the bladder, rectum, ureters, and the peritoneum, and it may be carried by the lymphatic vessels to the pelvic and inguinal lymphatic glands.
In nearly all cases of long standing the upper part of the vagina is involved. Sometimes the whole of the vaginal canal, from the cervix to the vulva, is infiltrated with cancerous growths.
The body of the uterus always becomes involved sooner or later. This is most apt to occur in those cases in which the disease begins in the cervical canal. The endometrium is affected by direct extension, the malignant disease being often preceded by some benign form of endometritis.
Sometimes the cervix becomes hypertrophied by general infiltration to three or four times its usual size.
The broad ligaments are very usually involved by direct extension of the disease. They become thick, hard, and very rigid, holding the uterus fixed in the pelvis. When only one ligament is affected, the uterus is drawn to that side. The ureters become involved by extension of the infiltration to their walls or by pressure upon them by the thickened broad ligaments.
The bladder, on account of its close relationship to the cervix, is always involved in the last stages. The disease may extend to the vesical mucous membrane, and symptoms of cystitis will appear. Sometimes the vesico-vaginal septum is destroyed and a urinary fistula results. Extension to the rectum is not so common. As the disease extends upward the peritoneum may be perforated, though this is an unusual accident. In most cases peritoneal involvement is preceded by local inflammation and by adhesions which prevent direct penetration of the peritoneal cavity.
The pelvic and retroperitoneal lymphatic glands become affected in the later stages of cancer of the cervix.
The inguinal glands are rarely involved in the last stages of the disease. Metastasis to remote parts of the body is unusual. Cancer of the cervix usually remains localized and does not become metastatic.
From this description it will be observed that in the early stages of cancer of the cervix the disease presents a variety of appearances. As cure of the disease depends upon its early recognition, it is of the utmost importance that the physician should be familiar with these early phenomena.
When cancer begins in an erosion of a laceration, we find that the eroded surface bleeds more easily than in the non-malignant condition, and is somewhat more elevated than the surrounding surface of the cervix. We may by palpation detect around the erosion a more or less indurated edge which is not felt around a benign erosion. The submucous structures of the cervix may feel brawny and indurated. If the erosion has become an ulcer, the indurated edges and the involvement of the deeper structures of the cervix are more marked. It must always be remembered that an ulcer of the cervix is very rare as a benign condition.
In the vegetating form of cancer of the cervix we may find small warty growths, or large cauliflower-like masses, or rounded or irregular protuberances growing from the surface of the cervix. There is here also felt an induration around the base of the growth and throughout the cervix.
A very striking characteristic of cancerous growths of the cervix uteri is their friability. The warty growths or cauliflower-like masses break off readily upon even gentle palpation, and profuse bleeding often results. There is no other disease of the cervix in which the outgrowths are of such a friable and vascular character. Even in the ulcerated form of cancer the edges of the ulcer are of this same friable nature.
When the disease begins immediately within the external os, this opening becomes enlarged, the cervical canal is destroyed, and there is presented the appearance of a deep conical excavation, with ulcerated, unhealthy edges, in the center of the vaginal cervix. When the disease begins still higher up, the cervical canal may be the seat of extensive destruction of tissue before any lesion is visible below the external os. Usually, however, the os is sufficiently open to permit the condition of the canal above to be seen.
When the disease begins in the racemose glands of the cervix, the nodules may be felt beneath the mucous membrane of the vaginal aspect of the cervix. The whole cervix is usually indurated and somewhat enlarged. The mucous membrane overlying the nodule may appear congested, and upon palpation it is found that the overlying mucous membrane does not glide readily over the nodule, but seems to be more than normally adherent to the underlying structures.
In all the forms of cancer of the cervix there is present to a greater or less extent a general induration of the cervix. The elasticity or resiliency of the cervix is diminished or lost; this is shown not only by the sensation upon palpation, but by the fact that the cervix is not capable of dilatation, by sponge tent or otherwise, as in the normal condition.
In the last stages of the disease the gross appearance is the same in all forms of cancer of the cervix. The cervix may fill the whole vaginal vault, sometimes hypertrophied to the size of the adult fist. The presenting mass is ulcerated, gangrenous, and covered with friable vegetations bathed in thin fetid pus and blood. The vaginal vault itself is usually involved by extension of the disease. The body of the uterus is found to be enlarged, and the mass of the cervix is held rigidly in the pelvis by the thickened cancerous broad ligaments.
In some other cases, instead of a protruding mass we discover an immense crater in the vaginal vault—a craterwith indurated edges and sides, surmounted by the body of the uterus. The size of the crater shows that the destruction of tissue has extended far beyond the normal limits of the vaginal and supra-vaginal cervices. The interior of the crater presents an ulcerated, sloughing surface.
There is no condition which should be mistaken for cancer of the cervix in the last stages. A sloughing uterine polyp presents superficially a similar appearance, but the gangrenous mass will be found surrounded by a ring or collar, often very attenuated, of healthy cervical tissue, and the presenting tumor is usually elastic to the touch, not unyielding and friable like the cancerous mass.
In the early stages of cancer the appearance resembles closely the erosion of a bilateral laceration of the cervix. In the simple laceration, however, the erosion is soft, not indurated; there are no palpable edges; the cervix is not brawny; and it will be found that the simple erosion yields to local treatment, while the cancerous erosion does not.
Syphilitic ulceration and the ulceration of lupus are very rare upon the cervix. Syphilitic ulceration sometimes presents all the gross appearances of cancer. The history, the microscopical examination, and the therapeutic test will enable one to make a differential diagnosis.
Cystic degeneration of the cervix should not be mistaken for the nodular form of cancer, for the cysts may be seen and punctured and their character determined.
Benign fibroid tumors of the cervix are very rare, are usually single, and are larger than the nodules of cancer.
In every case of doubt, in every case in which the physician has the least cause to suspect malignancy, microscopic examination of an excised portion of tissue should be made. Examination of tissue scraped off should not be relied upon. The most suspicious portion of tissue should be seized with a tenaculum and freelycut out. Pieces of tissue may be thus excised from two or more situations. In the nodular form of cancer a nodule should be seized and excised. It is perfectly justifiable, in cases which cannot thus be elucidated, to amputate the cervix and examine the whole structure.
The excision of small pieces of tissue may be done without an anesthetic, as little or no pain is caused by the operation. Bleeding is very slight, and may always be controlled by a light vaginal compress of gauze or cotton. If the case is not malignant, healing is rapid. The specimen removed should be placed in absolute alcohol and submitted to microscopical examination by an experienced pathologist.
Symptoms of Cancer of the Cervix.—A study of the early symptoms of cancer of the cervix is of the greatest importance. In the early stages the disease may be eradicated with every probability of permanent cure. Cancer of the uterus is more favorable for surgical attack than cancer in most other parts of the body. Excision of the disease is not done in the continuity of an organ or a structure, but the whole organ attached by distinct structures may be removed.
The great majority of women with cancer of the cervix come to the operator when the disease has extended too far to permit any radical treatment. Hopeless palliation is the only course to be followed. This unfortunate condition of things is due to the ignorance of the woman in regard to the significance of the early symptoms of the disease, and to the failure of the physician first consulted to insist upon a thorough examination as soon as any suspicious symptoms appear.
There is no one symptom of cancer of the cervix present in all cases, and all the common symptoms may be absent in exceptional cases until the last stages of the disease—until the disease has extended so far that cure is impossible. It is of great importance to remember this fact, so that the absence of one or more of the classical symptoms of cancer shall not engender a feeling of securitythat may cause the postponement of a thorough physical examination.
The usual symptoms of cancer of the cervix are hemorrhage, pain, and discharge.
Hemorrhage.—The first symptom that should direct our attention to this disease is bleeding from the vagina. Such hemorrhage often first appears as a menorrhagia—as an increase in the amount of blood lost at the normal menstrual periods. The loss of blood may be greater, and the duration of the period longer. Sometimes, if the woman keeps quiet during the period, the loss of blood and the duration are about as usual; but if she is upon her feet the loss is increased, and if she begins an active life immediately after the usual duration of the menstrual period has elapsed, bleeding may reappear for one or more days.
In other cases slight bleeding appears in the menstrual interval. A spot of blood may be discovered upon the clothing. The accustomed leucorrheal discharge may occasionally be streaked with blood. Such appearances are most frequent after long walking or standing or physical work, or after straining at stool, or very often after coitus.
If the woman has passed the menopause, the hemorrhage of cancer may appear as a re-establishment of menstruation—often to the satisfaction of the woman. This post-climacteric bleeding may occur with more or less regularity—every month or every three or four months—or it may appear as an occasional loss of blood after unwonted effort.
All hemorrhage of this kind, in women over thirty years of age, demands immediate and careful physical examination. Any bleeding from the vagina in a woman who has passed the menopause should arouse the gravest suspicion. From the slight hemorrhages just described the bleeding increases in intensity and duration, until there is a continuous loss of blood that saps the strength of the woman and produces the profound anemia characteristicof the last stages of cancer of the cervix, Sudden fatal hemorrhage in this disease is rare.
Painis not a constant accompaniment of cancer of the cervix in the early stages, nor is it in any way characteristic. The intensity and character of the pain may depend upon the direction of the growth of the disease. In some cases pain is absent throughout. The pain may be dull and gnawing in character, or it may be sharp and lancinating. The pain may resemble that of uterine colic. It may be referred to the back in the region of the sacrum, or to one or both ovarian regions, or to some part of the pelvis remote from the uterus, as the crest or the anterior superior spine of the ilium. It may extend down the posterior or anterior aspects of the thighs or into the rectum. In most cases of cancer of the cervix pain is not a prominent symptom until the later stages.
Dischargefrom the vagina may be present in cancer of the cervix before there are any symptoms of hemorrhage or pain. The discharge depends upon the position and character of the growth and the stage of the disease. It may first appear as an ordinary cervical leucorrhea in a woman previously free from such discharge; or the discharge of cancer may first appear as an increase of an accustomed leucorrhea. In such cases it is due to hypersecretion from the irritated cervical glands.
Later in the disease, when ulceration takes place or when the friable vascular vegetations appear, the leucorrhea becomes puriform in character and streaked with blood. It then becomes thinner, less mucous in consistency, and of a constant brownish color from the admixture of blood. The pus and débris from the breaking-down cancerous mass increase, and a horrible odor characteristic of the later stages of cancer of the cervix appears. This odor is not peculiar to cancer. It is caused by the sloughing tissue, and is observed when such a process occurs in other conditions, as in sloughing fibroid polyp. The discharge is irritating in character, and the ostium vaginæ, the vulva, and the inner aspectsof the thighs become excoriated in those who do not observe strict cleanliness.
Systemic absorption of the cancerous discharges produces a general septic condition, which, with the anemia from hemorrhage and the uremia from obstruction of the ureters, results in the so-called cancerous cachexia.
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 timeof 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.
Involvement of the pelvic lymphatic glands may sometimes be determined by vaginal palpation, one or more such enlarged indurated glands being felt lying posterior to the uterus. In most cases, however, glandular involvement can be determined only after the abdomen has been opened.
In general, it may be said that the operation of hysterectomy should be performed in all cases in which there is no cancerous involvement of the bladder and rectum, in which the vaginal disease may all be removed, and in which the uterus is freely movable.
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.
The remote results of hysterectomy for cancer of the cervix are poor. In the very great majority of all cases submitted to operation recurrence has taken place. It seems very probable that a few of the cases of recurrence are due to transplantation of cancer-cells into healthy tissue during the operation; but the vast majority die because all of the diseased tissues have not been or can not be removed. The hope for better results from the surgical treatment of cancer of the cervix depends, not upon improvement in the surgical technique, but upon the ability of the general practitioner to recognize the disease in its earliest stages, before inaccessible structures have been involved.
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. Some surgeons sew together the walls of the cavity to diminish as much as possible the raw surface. Others 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, atthe 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 (3per 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.
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, ametritisfollows 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 aperimetritis.
Acute inflammation of the endometrium sometimes occurs during the course of the exanthemata. Thechanges 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 boric-acid solution (ʒj to a pint of water) or of bichloride of mercury (1:4000) at a temperature of 100° to 110°, and the continuous use of saline purgatives. Active intra-uterine 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, moreradical treatment must be used. This treatment comprises frequently-repeated intra-uterine douches, thorough curetting of the uterus, and, finally, hysterectomy in extreme cases.
Every case of acute endometritis should be carefully watched and treated until the disease is cured. Acute endometritis, especially if gonorrhea is the cause, is very prone to become chronic and to extend to the mucous membrane of the Fallopian tubes and the ovaries.
Chronic inflammation of the endometrium, or chronic endometritis, is much more frequently seen in practice than the acute form. It may occur as a primary disease, but it very often occurs as the result of some other pathological condition of the uterus, as, for instance, subinvolution or uterine fibroid.
A variety of confusing terms have been used to designate the different forms of endometritis. There seem to be two chief forms of the disease: I. Chronic interstitial endometritis; II. Chronic glandular endometritis.
In the first form of the disease the interglandular tissue is chiefly involved. The spaces between the glands are infiltrated with connective-tissue cells.
In the second or glandular form of endometritis the disease affects the glandular apparatus. The utricular glands become much elongated, branched, and increased in number. The accompanying illustrations (Figs. 117, 118) show the microscopic appearance of interstitial endometritis and glandular endometritis.
These two forms of endometritis are often mixed, and the same uterus may present the glandular form of inflammation upon part of the endometrium, the interstitial form upon another part, and the mixed form upon still another part.
The gross appearance of the endometrium varies with the form of the disease and its duration. It will be remembered that in the mature uterus, in the menstrualinterval, the mucous membrane is a thin reddish-gray structure about 1 millimeter (1/25 inch) in thickness. In the different forms of endometritis the mucous membrane may become hypertrophied to three or four times this thickness. In some unusual cases the mucous membrane may become even still further hypertrophied, attaining a thickness of half an inch. A special name,fungous endometritis, has been given to the disease when it assumes this form. Microscopic examination shows that fungous endometritis is merely a mixed form of the glandular and the interstitial varieties, with a great increase of all the elements of the mucous membrane. In fungous endometritis the hypertrophy of the mucous membrane may be uniform throughout the body of the uterus or it may occur only in localized areas.