Reprinted from the New York Medical Journal for December .26, 1896. THE EARLY RECOGNITION OF UTERINE CANCER, WITH SOME REMARKS ON ITS TREATMENT* D. ERNEST WALKER, M. D. Within the last few years the importance of this subject has been more and more impressed upon my mind, and, while I shall not offer anything new as to the symptoms or treatment of this dread disease, I believe that these symptoms and the importance of their early recognition should he repeated and repeated and re- peated, until they can not he overlooked nor forgotten. Coming in contact with many cases of this disease, both in early and in advanced stages, I have noted time and again the woeful carelessness of medical attendants to whose notice these symptoms had been brought. I say carelessness, because after all that has been written and rewritten on the subject of uterine cancer, I can not believe that any man of ordinary intelligence who reads can be ignorant of the symptoms and signs of this disease when they are plain and unmistakable. I believe, there- * Read before the Society of the Alumni of the City (Charity) Hos- pital, October 14, 1896. COPYRIGHT, 18D6, BY D. APPLETON AND COMPANY UTERINE CANCER. fore, that repetition again and again is the only way in which to impress the importance of early symptoms of this disease upon the profession at large. And upon its early recognition depends the only hope of successful treatment. The observation of symptoms pointing to cancer depends, as a general rule, upon the family physi- cian, the successful treatment in most cases upon the specialist, and the recognition of symptoms of the dis- ease in its early stages is of as much importance to the one as to the other. But a few.days ago I took the histories of two women with cancer of the uterus too far advanced for any except palliative treatment. Both of these women had danger signals pointing to cancer of the uterus for months and had consulted their physicians about these symptoms. In both instances the trouble had been ascribed to the menopause, and no examination had been made until too late. The histories I obtained from these women did not lead me to believe that either of their physicians were ignorant men or that either failed to suspect the true state of affairs; yet both pa- tients were allowed to go on for months with the old threadbare explanation of the menopause to account for every symptom until the last hope of successful treat- ment was gone. To make matters worse still, each case gave a family history of cancer. Now what is the explanation of this? How is it that an educated physician within twenty-five miles of New York—yes, even under the shadow of the Academy of Medicine—can attribute frequent and increasing uterine haemorrhages, sanious and watery discharges, and pro- gressive anaemia, sometimes accompanied with pelvic pain, to the menopause, and make no examination, UTERINE CANCER. 3 though consulted again and again? Is it ignorance? In this age of societies, hooks, and journals one can scarcely think so. Yet if this be true in some instances, the early signs and symptoms of cancer of the uterus must be repeated until, like the child’s a, b, c’s, they must be recognized. How is it that the haemorrhages must even become foetid before some physicians seem to suspect or wake up from ergot, styptics, etc., to the fact that something must be done—when nothing can be done? Is it because of the fear of losing fees or that other men may get the patient? A greater mistake is never made, for if perchance, as often happens, the patient finds there has been a failure to recognize so serious a trouble until too late, and that valuable time has been lost, not only the patient and her family, but often all their friends, seek other advice and spread their story far and wide. How is it that a physician does not discover that a case is beyond all chance of benefit from his treat- ment until it is beyond the skill of any one? Is it be- cause he considers cancer of the uterus incurable—that it is sure death any way, and therefore unworthy of his best effort? He should read and he will find that sta- tistics show a large percentage of permanent recoveries from early removals. While all these things may play some part, I believe that most of the failures to make an early diagnosis of this disease, when it presents symp- toms, is due to carelessness. How prone one is to say to himself when consulted with reference to some of these symptoms, which at first appear trivial: “ Oh, this woman can’t have cancer—I know all the family and there is no history of cancer in it. It is not convenient to ex- amine her now, and besides, it is only the menopause causing a little disturbance. I don’t want to frighten 4 UTERINE CANCER. her by treating the matter seriously, and it must he all right.” So you prescribe something, and ascribe the symptoms to the menopause—remarking that when that is over she will be well. This, to her, explains every ill, for she has from her youth heard stories concerning the change of life and is prepared to expect anything. So she goes away and the symptoms continue, but as she does not suffer she does not consider it necessary to consult you again. Then you begin to think your linger- ing fear of cancer in her case was groundless, as you hoped it was, and you get rid of your twinges of con- science. About the time your last twinge is gone you see her somewhere and notice she has grown pale. She tells you that the symptoms she had before have con- tinued and of late have grown worse; that she also suffers sometimes now from pain. On examination you find a large growth involving not only the cervix but the vaginal wall, or a tumor of the body of the uterus with fixation, or some other equally serious condition of a like nature. This, I believe, often accounts for a failure to make an early diagnosis. We fight against our own conviction of the truth, and, knowing that we may he mistaken in suspecting cancer, we hope we are, and temporize with danger instead of sifting the matter at once. We dillydally and talk of the menopause instead of regarding these signals of danger as something which, if properly heeded, will save our patient from disaster. If we suspect a woman has cancer, is it just and right to conceal the suspicion in our own bosoms when to her it is a matter of life or death? Is it not our bounden duty to use every means in our power to decide the question, laying the facts before some member of UTKRINE CANCER 5 her family, or, if need be, before the woman herself? I fear that we go too far in the concealment of danger from the victim. Is it not analogous to allowing an in- dividual to walk unwarned across a bridge which is sure to fall and engulf him? Do we not sometimes sacrifice duty and the lives of others rather than place ourselves in a disagreeable position? It is so much easier to let things glide along, and in the end our fears may prove, as we wish them to be, groundless. I shall not go into the pathology of uterine cancer nor into a description of its different varieties, but shall merely mention its most prominent symptoms, the early signs .of its presence, which are so often unheeded These symptoms are practically the same in all varieties. Unfortunately, however, some cases do not present early symptoms, or, if they do, medical advice is not sought. With these this paper has nothing to do. The trouble is not that the symptoms are unknown, but that they are unheeded—so I shall not go deeply into symptoma- tology. This is more thoroughly treated in text-books than could possibly be done in the limits of this paper. The most prominent symptom is haemorrhage of an irregular character, both as to time and quantity, occur- ring usually about the menopause—an increase in quan- tity, and, perhaps, irregularity, if the menopause has not occurred; and a return of haemorrhagic flow if that pe- riod is past. Later, there is generally a watery discharge, sometimes of a bloody, serous character. Sometimes the first symptom is haemorrhage after coition. Any mod- erately profuse vaginal discharge occurring about the menopause, no matter what its character, should excite suspicion, and an examination should be made. The haemorrhages may often be mere stains on the linen. 6 UTERINE CANCER. When a small tumor, which you know a woman to have and which has caused no previous trouble, begins to enlarge and is attended with pain or luemorrhage, it becomes very suspicious, and so does any new growth or hardening of the cervix uteri which you observe. Pain is rarely a symptom early in this disease. Given a case of suspicious symptoms in a woman, especially about or following the menopause, our first duty is to make a thorough examination. If there is any enlargement of the cervix or body of the uterus, a hardened or patulous condition of the cervix, or any growth or ulceration in or upon it, the suspicion should be considered confirmed until it is disproved; for this is a case where it is proper to consider one guilty, so to speak, until he is proved innocent. This can be done only by microscopic examination of pieces cut from the cervix, or scrapings taken from the endometrium with a sharp steel curette, or both. The pieces should be cut as deeply as possible from the cervix, and the curetting should be very thoroughly done. The specimens should then he sent to some reliable pathologist, and if the re- port is unfavorable, you are brought to the consideration of the treatment that offers your patient most chances of permanent cure. It is, I believe, to-day an almost undis- puted fact with the profession that total extirpation of the uterus and its appendages offers by far the best chance of a permanent cure, always bearing in mind that the ultimate success of the operation depends upon its being done before the disease has extended beyond the tissues of the uterus proper, before fixation occurs, and before it has involved the vaginal wall or infiltrated any of the adjoining structures. When thus done, the per- centage of ultimate recoveries is very good. Hof- UTERINE CANCER. meier has reported thirty-three per cent, after four years; Fritsch, thirty-six per cent, after five years; Schauta, of Prague, 47.3 per cent, after two years; Olshausen, 47.5 per cent, after two years; the Dresden Klinik, 58.4 per cent, after two years; and Leopold, seventy-two out of seventy-six patients still well and with no return after five years and a half. Not only does early operation offer these advan- tages, hut it is free from one great objection to all other methods of treatment so far tried—namely, its perform- ance does not preclude the trial of other measures. In those cases which it does not permanently cure it pro- longs life—unless, as is rarely the case, the patient dies of the immediate effects of the operation. Therefore, a better chance is offered for the effect of any internal treat- ment, such as thyreoid or other glandular extracts or toxines. If these are ever effective, as is claimed, in large or advanced cancerous masses, they should prove much more speedily so in small ones, or in those tissues which are just taking on a cancerous condition. Thus, early operation would prove an aid rather than a detriment to their use, and consequently should not be opposed by the most skeptical. On the other hand, the same can not he said of the use of internal remedies and local applications, since they cause delays which are fatal to successful operation. Apparently the chances of a complete cure from operation are much better in those who are attacked with cancer of the uterus during or after the menopause than in those who have it before that period. This is probably explained by the fact that the generative organs are in a much more active state before than after the menopause, when atrophic changes begin, and the adja- 8 UTERINE CANCER. cent structures being also more active- and full of blood are more easily and rapidly invaded. In conclusion, I would suggest that the profession attempt in every way to eradicate from the mind of the laity the idea that the menopause is a sufficient expla- nation of every symptom affecting the female pelvic organs at or about that period; just as they are gradually getting rid of the old and pernicious belief that “ catch- ing cold ” is responsible for puerperal fever and other septic troubles. 219 West Forty-third Street.