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Carcinoma Uteri.

BY H. C. CROWELL, M. D., KANSAS CITY, Mo.

READ BEFORE THE WESTERN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, OMAHA, NEBRASKA, DECEMBER 27TH, 1894.

F this brief paper shall serve but one purpose, I hope it may be that of impressing physicians with the imminent necessity of examining at intervals of three to six months, every parous woman past 30 or 35 years, and indeed, I don't know as I should limit such examinations to parous women, since, in my own limited experience, I have had occasion to operate upon three who had never been pregnant. The only hope left these unfortunate women lies in a very early diagnosis.

We can not fall back upon our ability to perform successfully a vaginal hysterectomy to insure our patients immunity from the disease for the rest of their lives. We must each take every opportunity to enlighten our female patients approaching this critical period, upon the necessity of these frequent examinations. If every physician in the land will assume this task fearlessly he may be the means of saving many valuable lives by eradicating that much-dreaded disease, which, once well initiated, marches on to conquer in a most loathesome manner.

I think the experience of everyone will bear me out in the statement that often no symptom of the existence of the disease will be manifest short of a local examination; and, even then, we may observe only the merest suggestion of its presence; but, upon the slightest suggestion though it may be, we should not delay long with palliative measures before we subject sections of the cervix to thorough microscopical investigation. This means for diagnosis is always obtainable. Some months since, a case was sent to me for some bladder trouble, cancer of the uterus never having been suspected. In the course of the examination I observed a very small granular area in a fissure of the os uteri, which, upon being touched by a probe, bled easily. I immediately snipped a piece from the cervix. Microscopical examination demonstrated the presence of cancer. The patient presented none of the symptoms we are asked to note as evidence of cancer. was 38 years of age. Had at no time suffered from hemorrhages, pain or discharges of any character, save a slight leucorrhea. This patient, I consider, was given a good lease on life by prompt hysterectomy. Again, we shall meet a class who early present subjective symptoms which should excite our suspicion. In those cases which, at the menopause, are having a stormy time with excessive and frequent discharges of blood; or those which, after the change, have a reappearance of a stain even, we have presumptive evidence sufficient to put us on our guard and suggest careful investigation.

She

I might cite a case which recently came under my observation: A lady of strong physique, 50 years of age, who had passed the menopause without trouble at 46, called upon me to prescribe for her as she had, the day

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before, noticed a stain. I refused to prescribe until I should make an examination to ascertain if any discernible cause existed. Not being prepared that day, she promised to return the next day, which she did. A simple digital examination induced a profuse hemorrhage and revealed the presence of an excavation of the cervix, easily admitting the end of the finger. The broad ligaments were very much infiltrated, fixing the uterus as in plaster of Paris.

Cases without number, of this character, emphasizing the necessity of vigilance. Cases not presenting evidence of cancer in the cervix, but manifesting symptoms pointing toward that disease, may, after scraping out the fundus uteri, give positive microscopical evidence; but it must not be assumed that unless the microscope demonstrates the cancer cell that it is not present, for scrapings are very unsatisfactory for such examinations. In these cases the subjective symptoms should be taken into consideration, and our acts governed thereby. Having satisfied ourselves of the presence of carcinoma uteri, cervical or corporeal, what shall be our treatment?

I think experience has proven that only surgical measures are to be entertained. Vaginal hysterectomy constitutes our hope and that of the unfortunate patient when we can remove the whole disease. Alongside vaginal hysterectomy some would place high amputation when the disease is supposed to be located in the cervix. I think, however, that time has or must shake our confidence in this procedure, since large numbers of cases which bid fair to be suitable for cervical amputation have, after total extirpation, demonstrated infiltrations above the usual line of amputation. In one early case occurring in my practice, where, if there are cases in which an amputation can reasonably be entertained, this was one; cancer cells were found well up in the uterus. I have personal acquaintance with other cases where amputations were done and promptly followed by recurrences. I should, therefore, counsel against cervical amputation for malignant disease.

By vaginal hysterectomy we approach a much safer condition of total elimination of the disease, and nowadays add but little to the dangers from the operation of amputation. With increasing experience the immediate mortality of hysterectomy has been reduced from 24 per cent to 5 or 10 per cent in the hands of competent operators. In an early case with a movable uterus, one which may be drawn down, the operation is not difficult or tedious.

There are many variations in technique as suits each individual operator. Some prefer clamps, others ligatures. In my own hands, and I think my experience corresponds with that of others, there is no difference so far as mortality is concerned, between ligature or clamp. That the ligature is more surgical I am prepared to admit; but it possesses the element of requiring more time to complete the operation, and also more skill and dexterity on the part of the operator. By the clamp method, either with one large clamp on a side, including the entire broad ligament, or numerous smaller ones applied as the uterus is progressively removed, a uterus reasonably favorable for such procedure can be removed in from 10 to 20 minutes,

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while the same case operated upon by the ligature method would likely consume from one to one and a half hours.

The only case of vaginal hysterectomy I have ever lost was a very fat woman on whom I employed ligatures. There was the most pronounced prolapse of intestines I have ever seen. As a result a knuckle of gut adhered to the edge of the wound, which was probably not sufficiently inverted into the vagina, and an ileus ensued. Thorough laparotomy was subsequently done; the patient died in about ten days. I had one case of hemorrhage after removing the clamps, but reapplying them and packing with gauze averted any bad end. In one case I was able to remove the uterus without haste in nine minutes; patient was dressed and returned to bed in nineteen minutes. Cases which have never had children render vaginal hysterectomy very difficult, as I can attest, in three cases. I am of the opinion that such cases can be more satisfactorily and speedily done through the abdomen. I have also demonstrated to my satisfaction that in well advanced cases we may more completely remove the diseased tissues outside the uterus, by the abdominal route, with the patient in the Trendelenburg position. Such cases should, however, be prepared for the operation a day or two previous to opening the abdomen by thoroughly curetting and cauterizing the cancerous cervix and packing with gauze. By the abdominal route we can more readily see what we are doing, and more room is afforded for manipulation, The same steps, in so far as the uterine attachments are concerned, are gone through with by this method as per vaginam. Indeed, I think the time, in this class of cases, would be much shortened, and by a proper observation of necessary technique, just as safely.

I am disposed to think that in well advanced cases, a longer aggregate of years, in one hundred cases, would be secured by a thorough curetting, followed by the thorough use of the cautery and gauze packing or drainage, than by resorting to hysterectomy.

No reference has been made in this paper, thus far, to the medical treatment of cancer, since in the author's experience little has seemed to avail from such efforts. However, I must concede that my opportunity for extended observation has been limited and, therefore, my opinion would be worth little. I deem it proper to refer to the opinion of Dr. Wight, of Brooklyn, who seems to have met with some success in modifying, to say the least, the course of carcinoma when not admitting of removal by the knife. He makes use of bromide of arsenic in 1-40 gr. doses with some encouragement, as cases reported indicate by a lessening of the degenerated cancerous surface, by peripheral healing, with apparent prolongation of life, though no absolute cures are established.

The treatment of carcinoma with the toxines of erysipelas and the bacillus prodigiosus has met favor in the hands of some, while with others the results have been negative. While these agents should be borne in mind, we believe our hope and aim should be to arrive at an early diagnosis before the disease shall have invaded the vaginal cul-de-sac or broad liga

ments.

9th and Locust Streets.

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Ectopic Pregnancy-Extra Tubal.

By C. LESTER HALL, M. D., KANSAS CITY, Mo.

READ BEFORE THE WESTERN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, OMAHA, NEBRASKA, DECEMBER 27TH, 1894.

A

FAIR discussion of any one of the pathological conditions known and called ectopic gestation, demands more than a passing notice of them. all. The generic term is a synonym for the abnormal, a deviation from nature, and a tendency to evil results. To a perfect organism it is deemed impossible, and yet it has happened in cases where it is impossible to trace an exciting, pre-disposing cause. In these, the autogenetic cannot be excluded.

To the materialist, he who must trace an inward effect from an outward cause, this statement will be challenged as heterodox, but to the broader and more comprehensive view, it has a place in etiology. Along with this constitutional immunity must be recognized auto-infection, waywardness of nature, and the unexpected. A perfect tenement of the soul would bid defiance to all causes of its destruction from without or within, and decadence would be impossible, and we would live on forever. Such evidently was not designed in our architecture, and the structure of our bodies has been left weak in place and imperfect in form. This inherent vulnerability ever makes us a prey to the destroyer, and natural processes are perverted.

It must be admitted at the outset that nature's design is that the ovum should be fecundated and find lodgment within the uterine body, where the anatomical arrangements and physiological processes will best subserve the interests and well being of both mother and offspring. Reviewing the construction of the female generative organs, how the grafian follicle breaks away from its moorings and starts on its migratory journey to meet its affinity, depending upon the fimbria and ciliated epithelium for its safe arrival at its destination, is it not surprising that it is not more frequently lost to its natural course, and it is unreasonable to suppose that its fecundating mate, weary at its long delay, starts in search for that upon which depends its future existence? Failing to meet the object of its mission in the avenue of its natural travel, "nothing daunted" it presses onward to greater depths until it overtakes the maternal germ. Granting that "the normal function of the ciliated epithelium is to carry all the tube contents toward the uterus," it must be granted that it often fails of its mission in cases where no trace of destruction of the cilia is discoverable, where there exists no history of pre-existing tubal disease. In the primiparous woman-in the healthy woman, with previous pregnancies normal. No class or station in life is exempt from this accident.

The experiments of Dode in which he injected an emulsion of charcoal into the abdomen of a rabbit, and after several hours found the tubes filled with particles of charcoal, and his further experiment of injecting the ova

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ascaris lumbri-coides suis into the abdominal cavity, and in twelve hours found large numbers of these ova in the tubes, does not establish the theory of Tait, as to ectopic pregnancy being the result of former tubal trouble with the destruction of the ciliated epithelium, they only prove nature's way, which is not constant or invariable. If these experiments of Dode were not conclusive, there would be no such thing as ovarian, tubo-ovarian, tubal and abdominal pregnancy, or tubal abortion in women with healthy reproductive organs. Dode claims that an ovum which had escaped into the abdominal cavity would be taken up by the tube and carried into the uterus.

Whatever may be the consensus of professional opinion in reference to Tait's theory as to the etiology of ectopic pregnancy, it must be conceded that the majority of these cases are primarily tubal, and become intraligamentous and abdominal by rupture secondarily.

Accepting Tait's theory, it is difficult to reconcile the apparent inconsistency that many cases which are claimed as primarily abdominal, are in reality the result of tubal abortion, for it should, in a spirit of fairness, be admitted that a condition of the tube which would permit the escape of the fecundated ovum would also favor the escape primarily of the fecundating material.

The escape of this fecundating material may be brought in contact with the mother germ, just as it emerges from the tubal ostium, and constitutes what may be called fimbriated pregnancy, and not necessarily tubo-ovarian, and yet it may never break away from its attachments, but form additional attachments to the abdominal parieties, and be walled off from the general abdominal cavity.

The skepticism expressed by Lusk, Beale and others of the existence of primary abdominal and extra-tubal pregnancy, where the tubes are intact, and not in communication with the sac, make this question a debatable one.

The varied symptomatology of ectopic gestation, makes a diagnosis difficult and frequently impossible. It can be truthfully said that there are no pathognomonic signs of ectopic pregnancy.

The differential diagnosis between ectopic pregnancy and oöphöritis is often perplexing. Both conditions cause pain; both are accompanied with hemorrhage of uncertain duration and irregular return. The differential diagnostic sign as pointed out by Vertsinski, Thomas and Lebedoff, which they claim as characteristic, viz.: The varying size of the tumor in inflammatory conditions of the tubes and ovaries, "the tumor sometimes as large as an orange, and in only a few days can hardly be defined." This periodical variation in size is closely connected with menstruation and ovation. The same condition has observed in a case of ectopic pregnancy. While the expulsion of the decidual membrane is considered a valuable symptom, Lusk says that it is not a constant occurrence.

The American Text Book of Gynecology divides the diagnosis of ectopic gestation into two periods:

First, prior to tubal rupture or abortion.