Cancer of the Uterus.

NZMJ, 1924

By Ralph Worrall, M.D., M.Ch., Honorary Consulting Gyaecologist to the Syndey Hospital, Surgeon to the Coast Hospital.

Paper to open the discussion at the Medical Conference at Auckland, February, 1924.

Of knowledge of cancer it may be truly quoted:

“How little have we gained;
“How vast the unattained.”

Only by pooling individual experience, by world-wide co-operative research can we hope to gain an insight into the nature, causation and means of controlling this mysterious and devastating disease. The public in all countries is impressed by the alarming increase in the death rate from cancer, and we may therefore assume it will be correspondingly easier from henceforth to raise the funds necessary for research in all directions.

It would be a mere waste of time for me to reiterate the various theories of the causation of cancer as set forth in the text-books.

My own experience supports the view that hereditary is a factor. In over 20 per cent. of my cases a family history of cancer was elicited. In one of the most recent the mother and grandmother of the patient had died of cancer uteri.

That injury and chronic irritation are powerful provocative to cancer is admitted throughout the world.

This is seen in the remarkable frequency of cancer of the skin of the abdomen in the natives of the North-West of India from wearing a copper brazier of live coals in that situation as a protection against the cold, or the unusual incidence of cancer of the œsophagus amongst Chinese in certain districts who are in the habit of swallowing almost boiling rice.

We all warn people against allowing a rough decayed tooth to remain to constantly irritate the tongue and thus favour the development of tongue cancer as in the case of General Grant, but a large proportion of medical practitioners fail to realise the danger of leaving untreated a lacerated cervix with the chronic degeneration which almost invariably follows such an injury.

This should be regarded as a pre-cancerous condition no more to be ignored than leucoplakia of the vulva or tongue.

I have seen only three cases of cancer of the cervix in nulliparæ. Cullen gives 2 per cent. of the victims of cervical cancer as nulliparæ, whereas in cancer of the body of the uterus over 50 per cent. are unmarried or childless.

This relatively greater frequency of cancer of the body in the unmarried or childless may be partially explained by the greater frequency of myomata in this class and the admitted power of myoma to excited cancer or undergo transformation into myosarcoma. Studying my case sheets for only the past four years I find cancer of the body and myomata associated in four patients.

Erosions of the os uteri should not be allowed to remain, whether the lesion be an infective process causing a shedding of the squamous epithelium of the vaginal portion and a proliferation downwards of the columnar epithelium of the cervical mucosa or an eversion of the cervical canal resulting from injury with proliferation as a consequence. In the former case the treatment should be three or four applications of picric acid in spirit (saturated solution), or similar agent and in the latter by plastic operation.

In the out-patient department of the Syndey Hospital there are records of three women who ignored the advice that they needed the repair of a torn cervix uteri, and who several years afterwards presented themselves suffering from cancer.

The preventative treatment of cancer of the uterus then should consist in conducting obstetric practice with such care and skill that injuries are as far possible avoided and when such injuries do occur in repairing them without undue delay.

Secondly that all sources of irritation such as erosions, cysts, neoplasms, should be treated and removed.

In dealing with the prophyllaxis of cancer of the cervix one should mention to condemn the too prevalent practice of performing sub-total, instead of total, hysterectomy when removal of the uterus is called for in such conditions as chronic metritis (bleeding uterus) or myoma associated with injured or degenerated cervix.

I hope a unanimous opinion will go forth from this Congress that to remove part of the uterus which is wholly diseased is reprehensible. Such an operation can but half cure the patient and will leave her exposed to the danger of cancer.

I have reported three cases of cancer attacking the stump of the cervix left after sub-total hysterectomy (The Medical Journal of Australia). Since then I have seen two other similar cases. My colleague, Dr. Cedric Bowker, has had one, while a considerable number have been reported in the medical journals.

SYMPTOMS.—Students should be taught that there are no symptoms absolutely characteristic of cancer, but that unnatural hæmorrhage and unnatural discharge are cardinal symptoms which it is the duty of the physician to explore with a thoroughness which leaves nothing to chance.

If unnatural hæmorrhage and unnatural discharge should occur at the menopause it should be at once assumed that cancer is present until the contrary is proved. Even now one hears from patients that “the doctor told them the bleeding was due to change of life.”  “He made no examination.” One might justifiably use very strong language regarding such neglect of duty; it is not following the golden rule “to do as we would be done by.”

Unnatural hæmorrhage and unnatural discharge are the only symptoms which count from a curability point of view.

The string of symptoms which the student has impressed on him, such as of pain, wasting, interference with the urinary and bowel functions, cachexia, etc., are really terminal symptoms; when these are present one may abandon hope of a cure.

Diagnosis of cancer of the cervix is usually easy because it is not early. It is not early owing in some degree to the remissness of medical practitioners and largely to the ignorance of the public.

Early diagnosis being the very foundation of successful treatment this Congress might appropriately recommend the Government to give the widest publicity to medical views by inserting periodically in the public press and by posting in every post office and railway station some such notice as this:

CANCER.

“Curable in the early stages. Do not delay a moment in consulting a doctor if you have a lump or sore in or on any part of the body; or if you have stomach or bowel trouble, or if there is any bleeding or discharge.”

The cardinal signs of cancer of the cervix are:—(1) Hardness and induration throughout, even on the surface, conveying the feel of wet indiarubber; (2) friability; (3) vascularity out of all proportion to the injury inflicted by the examining finger. With this combination present the diagnosis of cancer may be confidently made.

In cancer of the body one is guided by the hæmorrhage and discharge and perhaps some slight enlargement.

Examination of the curette scrapings is unreliable and curettage dangerous. The curette is very liable to perforate the uterus owing to its softened and thinned-out condition, and apart from this risk I am inclined to think curettage favours spread. The mortality rate of ordinary complete hysterectomy is very small and justifies the performance of the operation in elderly women suffering from hæmorrhage and discharge without waiting for certainty of diagnosis. The improvement in the general health which follows the operation in such cases is very striking even when the lesion present is benign.

CANCER OF THE BODY OF THE UTERUS.—Since 1908 I have performed complete hysterectomy for cancer of the body of  the uterus nineteen times, for sarcoma once and for chorio-epithelioma once.

In operating for malignant disease of the body of the uterus I have removed the appendages but not the parametrium or the glands.

In the series there was one post operative death (embolism)—5 per cent.

Two are known to have died within two years. Seven (15.5 per cent.) are known to be well five years or over after operation, one after four years, two after three years, four after two years and two after one year. None of the others replied to letters.

In cancer of the body then it appears that the primary mortality rate after operation is small and the prospect of permanent cure fairly good; better than that offered by radiology or any other treatment at present known.

CANCER OF THE CERVIX.—In moving to new offices some twenty years of my records of Wertheim’s operation were lost. These were my earlier cases. Speaking from memory, there were five fatalities in the series (25 per cent.).

I have notes of 40 Wertheim’s operations since then with three deaths.

Of the 37 who survived the operation one is known to have died within the first year, three within two years, three within three years, three within four years. Two are known to be well after one year, two after three years, three after four years, three after five years, two after six years, one after seven years, and one after thirteen years. Assuming that all those of whom no tidings could be gleaned have died of a recurrence, which is unlikely, seven cases have a fair chance of cure and seven (17.5 per cent.) in all probability have been cured.

No case operated on could be said  to have been in an early stage.

Operation was never refused if there seemed to be the slightest chance of success.

Those patients who died of the operation had a relatively merciful ending.

Of the survivors I know of only one who was probably worse off than before. This was a young Russian, in whom there was a recurrence or continuance of the disease and such rapid growth that colostomy for the relief of obstruction of the pelvic colon became necessary a few months after operation.

In two cases the recurrence took place in the scar of the vaginal vault. All the others in whom recurrence took place were spared the fœtor of the discharge which renders the cancer victim abhorrent to herself and those around her.

Three had a ureteral fistula following operation. One had vesical fistula from sloughing of the bladder wall off which growth had been dissected. It would have been better to have resected the wall in this case as I did in two others, in which the bladder wall was similarly affected.

Both ureters were implanted after division into the bladder in one case. The patient after recovering from an attack of pyelitis suffered no disability from the procedure. The pelvic glands were ostensibly enlarged in only three cases.

One patient was single; three were nulliparæ.

The oldest patient was 65 and the youngest 30. The pathologist reported the growth to be adeno-carcinoma six times, cylindrical celled carcinoma  six times, all the others squamous celled. Two were typical papillary (cauliflower) growths; fifteen were entered as excavating (crater-like). The papillary form is the most favourable and “the boring” (intra-cervical) carcinoma the most insidious, difficult and dangerous.

The technique employed was Wertheim’s, except that peritoneal gauze drainage into the vagina was used instead of the sub-peritoneal advocated by him. The latter appeared to me to favour ureteral fistula.

On opening the abdomen one takes a bird’s eye view of the parts. A thickening and wrinkling at the junction of the bladder and uterus is ominous, indicating probable invasion of the bladder wall; if extensive this precludes hope of cure by operation.

Enlarged glands may be removed unless very fixed. In my last case Dr. K. Inglis reported the enlarged glands showed no evidence of cancer.

The ureters are most likely to be injured at their junction with the bladder but unceasing vigilance is necessary throughout the entire operation. After dividing both round ligaments and the peritoneum between them it is a good plan to bore the finger down between uterus and bladder exactly in the middle line, a relatively less vascular area, and then separate each side from below and outwards.

I have also practised this manœuvre which I learnt from Professor Watson, in separating the gall bladder when it is decided to begin at the fundus.

The handled needle which I show is of value in passing ligatures beneath deep lying veins and in securing the cervico-pelvic folds on each side.

The greatest care should be taken in handling the ureter and in separating it only to the extent necessary to remove the parametrium, thus minimising the risk of ureteral fistula from necrosis of a small area cut off from its blood supply.

A fistula may not occur for a week and is a complication producing great misery.

The operation is begun by applying the sharp spoon and cautery to the growth in the vagina; yet not too vigorously lest the bladder or bowel be perforated or the junction of body and cervix be so thinned that in the course of the operation making traction, the body comes away from the cervix, thus greatly increasing the danger of implantation of cancer cells. Disinfection of the vagina follows and care is taken to exclude the possibility of pyometra.

The Victor Bonney vaginal clamp is easily applied and securely segregates the growth.

In cancer of the cervix uteri dogmatic statements as to the prospects from operation are as much out of place as they are when speaking of cancer in most other regions.

There is not a surgeon who would not gladly surrender whatever earnings he may derive from operations for cancer if only it were made clear to him that a method of treatment had arrived which gave better end results than surgery could offer.

My experience and study impel me to regretfully say “this time is not yet.” I have used all the radium in the Sydney Hospital and that belonging to Drs. McMurray and Langlow Johnson without being able to satisfy myself that the march of the disease had been materially delayed. I have seen deep X-ray therapy tried once (inoperable cancer of cervix following sub-total hysterectomy eight years previously)—it caused much suffering and collapse and, I am informed, no real benefit.

During my medical career I have seen various treatments for cancer come and go; only surgical methods have survived. Surgery does undoubtedly cure a considerable number, while a larger number are by surgical means restored for a time to life and hope.

By educating the people to immediately apply for treatment on the appearance of the first unnatural symptom or sign and by better technique our present results will surely improve.

Unfortunately in Australia, and in a lesser degree in Great Britian, cancer patients are split up amongst many surgeons, so that no one surgeon acquires a wide experience such as is the rule in the great clinics of Vienna, Paris, Berlin.

War experience has shown that concentration of similar cases has greatly aided successful treatment.

The best substitute for this is that pooling of individual experience which it is the object of this Congress to effect.

I have given you, I hope, a plain tale of mine, and am confident that in listening to yours I shall well be repaid for my journey of seas and lands.