VAGINAL HYSTERECTOMY FOR CANCER—27, CASES. BY W. F. McNUTT. M.D., M. R. C. S., ETC. PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDI- CINE. MEDICAL DEPARTMENT. UNIVERSITY OF CALIFORNIA. 'READ BEFORE THE SAN FRANCISCO COUNTY MEDICAL SOCIETY.) R F PRINT FROM Pacific Mfoical Journal JUNE, 1894. Vaginal Hysterectomy for Cancer 23 CASES. By W. F. McNUTT, M. D., M. R. C. S., etc. Professor of Principles and Practice of Medicine, Medical Department, University of California. (Read before the San Francisco County Medical Society.) Three years ago, when the State Medical Society met in Los Angeles, I reported five cases of vaginal hysterectomy for can- cer. Since then I have made 14 vaginal hysterectomies, and four times have removed the uterus in part for cancer. It is not the purpose of this paper to deal with the etiology or pathol- ogy of cancer of the uterus. To my mind the operation has not met with the cordial support that it deserves; many physicians, surgeons and gynecologists still oppose it on the grounds that it does not cure, that it does not prolong life, that it is dangerous. Let me say to the gentlemen who oppose hysterectomy for can- cer on the ground that the results are not as beneficial or per- manent, as is extirpation of any other organ for cancer, the fault is not in the uterus, but in ourselves. We either fail to make an early diagnosis, or do not operate promptly when the diagnosis is quite certain. It cannot be that cancer of the uterus is more prone to return when removed early than cancer of the breast for instance. In other words, it is reasonable to suppose that cancer of the uterus will be confined longer to the uterus before implicating contiguous tissues than will cancer confine itself to the breast or lips or tongue, for instance, before affecting neighboring tissues or glands. The uterus is an or- gan suspended, as it were, by ligaments, which certainly are not as likely to partake of the diseases of the uterus as the con- tiguous tissues about the breast in case of cancer of that organ. The important question is, how can we make an early diagnosis of cancer of the uterus ? It does not do to wait until the uterus becomes fixed, as removal then is very likely to be fol- lowed by a return of the disease. While hysterectomy for can- cer does not receive the endorsement by the profession generally, as does removal of the breast, at the same time the operation has become quite too frequent to justify one in occupying the time of a society with a detailed account of each case. I believe 2 Vaginal Hysterectomy for Cancer. that every case for several years to come should be reported, omitting details and technique; giving only symptoms that may assist in early diagnosis, the stage of the disease at time of oper- ation, and the results, immediate and final. The three import- ant vital points in regard to hysterectomy for cancer, are, first, diagnosis; secondly, stage of the disease or condition of the adnexa at the time of operation; and, thirdly, final results. Of the five cases which I reported in detail to the State Soci- ety in 1890, the first, Mrs. “ B.,” was operated on Nov. 27th, 1888, at the age of 55. She had ceased to menstruate at 41, and hemorrhage reappeared at 53; she had had hemorrhage two years before the operation. In this case it was not her fault that she had gone two years with cancer, before the uterus was removed, as she had consulted several physicians during the time and had received treatment to arrest the hemorrhage. Mrs. “ B.” died Feb. 28th, 1894, of cancer of the pancreas. I made a post-mortem. She lived five years and four months after the operation; she had no cancer history. She was greatly emaciated when I operated, but soon regained her weight and maintained it up to to six months before she died; she was ex- tremely emaciated at the time of her death. This was not, of course, a return of cancer from extension. Case 2. Mrs. “P.;” operated on July 25th, 1889; had had hemorrhage many months before the operation, and had been treated. Uterus should have been removed at least a year sooner; the anmmia at time of operation was extreme. She re- mained well for about 18 months, died two years and a half after operation from return of cancer. Case 3. Mrs. “F.;” operated August 11th, 1889; age 68i; had cancer of the uterus and ovarian tumor; made double operation. The old lady recovered her health; gained 25 pounds in four months, and died two years after in Washington; cause said to be cancer of the rectum. No history of cancer in the family. Case 4. Aged 32; no cancer history; had been treated many months for hemorrhage and foul-smelling discharges; adnexa were involved; both ligaments were removed with uterus. Patient died 18 months after; cause said to be Bright’s dis- ease. Case 5. Mrs. “ W.;” age 38; operated Dec. 3, 1889, died of return of cancer about one year after operation. Vaginal Hysterectomy for Cancer. 3 The 18 cases of cancer of the uterus operated upon since are as follows: Case No. 0, Mrs. “ W.;” operated on May 20th, 1890, had cancer history, one sister died of cancer of uterus (had never borne children). Mrp. “ W.” died fourth day after operation. Variety epithelial. She should not have been operated upon; she was addicted to the use of morphine, and had been in the habit of taking 12 to 14 grains daily; before operating I under- stood she used about three grains daily. Persons who use morphine to such extremes will nearly always succumb to any considerable surgical operation. Case 7. Mrs. “ E.;” age 38; operated May 15th, 1890; had never borne children; uterus fixed, bad had hemorrhage many months; brought to the city on a bed, had been treated in Washington. Removed the cervix, coned out the uterus, leav- ing merely a shell; tied the uterine arteries and packed. Made a good recovery; sent home in six weeks; regained her health and strength; should have been operated upon at least a year sooner. Her physician had diagnosed it as cancer, but had had no experience with hysterectomy. Variety epithelial. Lived over two years. Case 8. Mrs. '‘H.;” aged 45; operated upon Sept. 25th, 1890; no children; no cancer history; had suffered great pain; lost much blood and been treated many months; should have been removed at least one year before; uterus fixed; variety scirrhous; died about six months after operation. Case 9. Mrs. “C.;” age 4G (German); operated Jan. 7th, 1891; lives in city; had four children; mother living, aged GO; father died aged GO; had hemorrhage and foul-smelling dis- charges only a few months before the operation; uterus not fixed; not much pain nor emaciation nor loss of strength; went about the house 21st day after operation; soon recovered her weight and strength; is still in excellent health; time, three years and three months; variety epithelial; no cancer history. Case 10. Mrs. “ L.;” age about 44; operated Oct. 22d, 1891; three children; no cancer history; had hemorrhage very abund- ant and foul smelling discharge several months; suffered much pain; uterus fixed; adnexa involved; operation was very difficult; died third day after operation; hemorrhage from branch of ovarian artery; had used both ligatures and clamps in this case. 4 Vaginal Hysterectomy for Cancer. I saw there was still some oozing, but packed the vagina, which seemed to control the bleeding; the hemorrhage took place into the abdomen above the packing—packing is very well for oozing from branches of the circular artery, but bleeding from the ovarian should be arrested by clamps; failing in this, the abdomen should be opened and the artery ligated. This case ought not to have died; variety scirrhous. Case 11. Mrs. “ F.;” age 39; operation Nov. 12th, 1891; no children; hemorrhage for several months and considerable pain; great deal of watery, bloody discharge; odor very bad; a large, obese woman with very weak and irregular heart and pulse; positively fatty infiltration of heart, and possibly fatty de- generation; died two and a half days after operation. Appa- rently never recovered from anesthetic, or shock, or both. Case 12. Mrs. “McC.;” age 34; operated May 14th, 1892; mother died of cancer of the uterus; age 53; married at 15; first child born at 18; hemorrhage and pain with loss of strength and cancerous cachexia, had been treated several months for hemor- rhage; went home in six weeks; said to be indications of return when last heard from, three or four weeks ago, time two years; variety epithelial. Case 13. Sears, age 29, operated July 9th, 1892. This case was reported in detail in the Pacific Medical Journal, April, 1893. She was three months pregnant, and the vaginal hyster- ectomy was a very difficult one. I finally succeeded in turning the uterus over, and split it in order to get room to ligate or clamp. With the report of the case is also given Dr. D. W. Montgomery’s interesting microscopical report. She made a good recovery but has since died from return of the disease; variety epithelial. Case 14. Mrs. “B.,” age 54, widow, menopause occurred at the age of 42, mother and sister died of cancer; hemorrhage and pain for past eight months; operated Aug. 11th, 1892, cancer epithelial, no adhesions, the operation was completed in 16 minutes, clamps used, only one on each side, she left her bed on the 13th day and returned to her home on the 21st, was well when last heard from, a few months ago. Case 15. Mrs. “B.,” aged 58, operation Jan. 1st, 1893, no children, scirrhous, with extensive adhesions and implica- tion of appendages, removed cervix, coned out the body to Vaginal Hysterectomy for Cancer. 5 a shell, clamps, uterine arteries, and packed, lived about one year. Case 16. Mrs. “ G.,” age 53, operated Jan. 8th, 1893, has had four children, no cancer history, pain, hemorrhage and very offensive discharge for nearly a year, was treated continuously, operation should have been done six months sooner, made a good recovery and is still living. Case 17. Mrs. “H.,” age 42, operated Jan. 19th, 1893, mar- ried at 19, two children, no cancer history, some pain, severe hemorrhage, extreme anaemia, uterus measured 4£ inches, no adhesions, uterus movable, made a good recovery and is per- fectly well at present, variety epithelial. Case 18. Mrs. “S.,” operation Aug. 6th, 1893, two children, menopause 46, hemorrhage past year, great pain, emaciation and weakness, uterus fixed, very much adhered, vaginal wall to left involved, should have been operated on a year before, recovered from operation very well, pain was continued and cancer re- turned; died in March, 1894. Case 19. Mrs. “ C.,” age 52, operation Sept. 4th, 1893, three children, no cancer history, hemorrhage, pain and emaciation principal symptoms, portion of vaginal wall involved, which was also removed, patient still well, no pain or hemorrhage, but dis- ease is returning in the wall, variety epithelial. Case 20. Mrs. “ McL.,” age 41, operated Feb. 21st, 1894, no cancer history, has had eight children, youngest five years old, mother living, pain, hemorrhages and discharges offensive odor, emaciation and great weakness, adhesions, especially to bladder, is very well at present. Case 21. Mrs. “H.,” the record of whose case I lost, was from Virginia City, about 50 years old, came down complaining of great weakness, emaciation and hemorrhage, the uterus was fixed, appendages involved, and too late to make hysterectomy; I amputated the cervix and coned out the uterus, and tied the uterine arteries and packed. She regained her health, and her daughter, who was here a few months after the death of her mother, said she lived 27 months after the operation; died from the return of the cancer. Case 22. Mrs. “E.,” operated on April 26th, 1894, age 46, had four children, youngest 18, no cancer history; pain, hemor- rhage, enlargement, induration and uterus fixed were her symp- 6 Vaginal Hysterectomy for Cancer. toms. So firm were the adhesions that it was not prudent to remove the uterus. A high amputation of the neck was done in this case and arteries clamped. A careful microscopical examination was made in nearly all of these cases, either before or after the operation, and in most of them one or more consultations were held before the opera- tion was determined upon. Most of them needed no assistance from the microscope to make a diagnosis. The examination was made with a view of ascertaining if in cancer of the cervix the dis- ease spread only in a lateral direction. JohnWilliams, of London, stated such to be the rule, and that in cancer of the cervix, an amputation of the neck was all that was necessary for the removal of the disease, thus obviating the extirpation of the whole organ. Dr. Montgomery’s examination shows that in cancer of the cervix, the disease often follows up the mucous lining of the uterus, involving the whole membrane to the fundus, and at times dips into the tissues, displacing and destroying them. The assertion that cancer of the cervix only spreads laterally is not borne out by the cases, consequently ampulation of the cervix for cancer is not a safe or reasonable operation, as it cannot be ascertained in any case until after the womb is removed, how far towards the fundus the disease has progressed. I have tried to follow up my cases after operation and will continue to do so and report the results and let the facts determine the merits or demerits of the operation. So far, the cases that were operated upon while the uterus was movable, have given satisfactory re- sults. The condition at time of operation in many of the cases goes to show that the disease is not yet always recognized early in its existence. Of the 23 cases, three died within a few days after the operation; one, the morphine case, where 12 to 14 grains was the daily average amount, one from extreme fatty infiltration of the heart and probably some degeneration as the result of infil- tration, and one from hemorrhage, entiiely my own fault, the adhesions were extensive, the operation was very difficult and the bleeding was excessive. Bleeding from the wall of the vagina, or as the result of breaking up adhesions about the cer- vix is readily controlled by the packing, but the operator must positively assure himself that there is no hemorrhage from the higher adhesions or ovarian branches. If these cannot be reached per vaginam, the abdomen should be opened and the vessels secured. I have a specimen in my office, brought tome a few days ago by Dr. Pond, City and County Hospital, where Vaginal Hysterectomy for Cancer. 7 there is a large vein running direct from the left ovarian vein to the left renal, entering the left renal vein about a quarter of an inch inside the spermatic. A vaginal hysterectomy in this case, with removal of the ovary, is often done (and which was done in some of the cases reported), might give fatal hemorrhage unless the vein has valves. These cases show that vaginal hys- terectomy is a safe operation; that the younger the patient the greater tendency the disease has to return, and that when the uterus is fixed by adhesions the prognosis is bad. When the uterus is free and movable the operation is satisfactory and will probably yield as good results as the removal of cancer in any other portion of the body; but this requires an early diagnosis, and how can an early diagnosis be made ? There is no pathog- nomonic symptom. Sometimes by removing a portion of the cervix or by curetting, the microscope gives quite positive assist- ance, not always. The last case reported, operated on ten days ago, I felt morally sure of the diagnosis; Dr. Rivas, who saw the case in consultation, considered the diagnosis absolute. I sub- mitted a small portion that had been removed to Dr. Montgom- ery, with negative results; notwithstanding, I operated. The adhesion to the bladder and rectum were so absolute and the adnexa so fixed that the uterus could not have been removed without endangering the patient’s life. Dr. Montgomery exam- ined the removed cervix with the following results: “ I have examined the cervix uteri you removed from Mrs. E., and although I do not get indubitable evidence of cancerous infiltration, yet many things point that way, and so strongly, that for the patient’s sake it ought to be treated as cancerous. In the cervix there are many cysts lined with actively proliferat- ing epithelium, and in some places there are alveoli filled with actively proliferating and a typical epithelium. In no section examined, however, had the epithelial infiltration extended at all deeply. There was also found considerable amount of hya- line degeneration—a sign also looking to the presence of malig- nant disease.” The early diagnosis of cancer must be made from the family history, age, emaciation, cachexia, pain, hemorrhage, character of the discharges, and a good deal must finally rest with the personal experience of the examiner. It is not more difficult to diagnose cancer of the uterus, than to differentiate cancer of the stomach, or bowels, or kidney, or bladder, or pancreas, etc.