ON THE CHOICE OF METHODS IN THE TREATMENT OF UTERINE CANCER. BY REEVES JACKSON, A.M., M.D., PROFESSOR OF GYNECOLOGY IN THE COLLEGE OF PHYSICIANS AND SURGEONS OF CHICAGO, ETC. FROM THE MEDICAL NEWS, January 18, 1890. [Reprinted from The Medical News, January 18,1890.] ON THE CHOICE OF METHODS IN THE TREATMENT OF UTERINE CANCER. By REEVES JACKSON, A.M., M.D., PROFESSOR OF GYNECOLOGY IN THE COLLEGE OF PHYSICIANS AND SURGEONS OF CHICAGO, ETC. It is now very generally believed that cancer of the uterus is a local disease, and that at some stage of its existence it may be permanently removed. Likewise, it is understood that the curable period in the history of the disease is usually a very early one, and that the most favorable time for operative measures has very frequently passed before the pres- ence of the disease is known or its nature recognized. Equally true with these propositions is a third- namely, that in order to effect a permanent cure the removal of the disease must be complete. If any portion be permitted to remain, recurrence will surely manifest itself. The modern methods by which the removal of uterine cancer is essayed are chiefly three in num- ber, as follows : i. Amputation or excision of the diseased struc- tures by knife, scissors, or curette. 2. Actual or chemical cauterization. 3. Extirpation of the entire uterus. 2 JACKSON, The first and second of these methods may, of course, be variously combined. I desire to discuss and compare these plans with the view of determining the question: which of them should be preferred for the radical treatment of cancer of the uterus ? If the theory of local origin and limitation upon which all of these methods are based be true, it would seem unimportant, so far as permanency of result is concerned, which method be chosen, the only essential factor being thoroughness of removal; and the operator might feel at liberty to choose the method which sufficiently abundant experience may have shown to be the safer in immediate result. And why not? For various reasons known to themselves certain operators have given preference apparently to one of the above mentioned methods, and adopted it to the entire or comparative exclusion of the others; and, as a result, we are now in posses- sion of a sufficiently large number of observations, extending over a sufficient length of time to enable us, with a fair degree of accuracy, to estimate prop- erly the relative value of the methods in question in respect to their immediate mortality and their re- mote results-the latter as bearing especially upon the all-important question of recurrence or reappear- ance of the disease. Partial Removal of the Uterus.-In 1882 Dr. W. H. Baker, of Boston, reported the results of high amputation performed in twelve cases of cancer of the uterus, in which it was hoped the entire disease could be removed.1 No death occurred from the operation. In one case the disease returned after two months, death occurring in seven months. In another the disease returned almost immediately, and death took place in fifteen months. A third died three months after the operation. In a fourth recurrence took place nine months after operation : date of death not stated. In 1888, at the meeting of the American Gynecological Society, Dr. Baker stated that five of these women were living and well at periods of from six to ten years after the operation. At the same meeting Dr. Thaddeus A. Reamy2 reported the results which he had obtained by am- putation in 55 cases. These were selected from about 300 cases of uterine cancer of all grades, be- cause of the apparent possibility in them of entirely removing the diseased structures. There were two deaths-a mortality of 3 6 per cent. From Dr. Reamy's report it appears that in 2 of the cases the ultimate result was unknown; in 14 there was recurrence of the disease within one year and subsequent death; in 8 there was recurrence in two years; in 4 there was recurrence at periods varying from two to four years. In 20 there was no recurrence, the periods of immunity being from two to eight years, and 2 of the patients included in the number died from other causes. Of the entire num- ber, 3 others died from other causes, and free from recurrence of cancer, at twelve, thirteen, and four- teen months respectively after operation. TREATMENT OF UTERINE CANCER. 3 1 American Journal of Obstetrics, 1882, p. 265. 2 Transactions, 1888, p. 185. 4 JACKSON, In the Annals of Gynecology, January, 1889, Ver- neuil records his experience with this method of treatment. His cases were 22 in number. There were 2 deaths. In 9 of the cases there was recur- rence of cancer in the cervix, while in 12 the cervix remained free from disease, although 1 of the patients was under observation for seven years. Verneuil classifies his cases into two series, the first series em- bracing the cases operated upon down to the end of 1884, being 17 in number, and the second series in- cluding those operated upon since 1884, 5 in num- ber. The average length of life after operation in the first series was twenty-three months, and in the second twenty-nine months. In 1887 Hofmeier published a table of 96 cases in which partial amputation was done at Berlin. The mortality was 7.4 per cent.; 19 of these patients were living at the end of four years after operation. Since March, 1882, I have performed partial am- putation of the uterus for cancer in 30 cases. Two deaths resulted directly from the operation-a mor- tality of 6.6 per cent. Of the 28 who recovered n are living and were in good health very recently. The periods which have elapsed since the date of the operation in these cases are as follows: In 1 six years and three months; 1 five years and nine months; 3 over four years; 1 over three years; 3 over two and a half years. In addition to the fore- going 2 others are living, but as the operations were made upon them less than two years ago, I have not included them. Some of the cases are embodied in this report TREATMENT OF UTERINE CANCER. 5 only for their bearing on the question of immediate mortality, the disease having been so far advanced at the time of operation as to render it certain that the affected tissues could not be safely removed, and in which amputation with accompanying or subse- quent curetting or cauterization was used only as the most efficient means of palliation. Such cases were Nos. i, 3, 8, 16, 22, 25, and 26 of the table. Deducting these 7 and the 2 deaths, 9 in all, from the entire number, it leaves 21 from which to compute the ultimate result of the operation. As already stated, 9 of these are alive and well, from two and a half to more than six years after opera- tion. From the table on next page it will be observed that the earliest period in which symptoms of recurrence appeared after operation was four weeks, in a single case, and I am quite sure I did not in that instance remove all of the disease. Indeed, in very many cases-I think I may say all-it is impossible to know in advance of, or during, an operation the extent of cancerous involvement, and hence it is equally impossible to know, except through lapse of time, whether an operation will be or has been radical. And this applies to all operative methods. Whenever symptoms of so-called recurrence are manifested within a few months after an operation, it may very generally be accepted that the fact indi- cates a continuance rather than a recurrence, and that the disease in such cases has only been partially removed. But while this inability to define the anatomical limits of cancer must always affect the 6 JACKSON, Table showing the Results in Thirty Cases of No. Initials of patient's name. Residence. Age. Date of operation. I R. M. Englewood, Ill. 4i March 17, 1882 2 K. M. Chicago 45 April 17, 1883 3 S. M. Chicago 45 June 16, 1883 4 N. A. L. Ottawa, Ill. 32 August 15, 1883 5 M. S. 54 Jan. 29, 1884 6 T. Y. Chicago 41 Feb. 6, 1884 7 G. M. Chicago 57 April 12, 1884 8 L. G. Chicago 26 April 14, 1884 9 O. S. Chicago 41 May 25, 1884 IO J- M. Mattoon, Ill. 38 May 5, 1885 II A. M. Chicago 48 May 30, 1885 12 H. H. Chicago 72 June 17, 1885 13 M. W. Dubuque, la. 5o Sept. 23, 1885 14 M. J. Chicago 40 Nov. 25, 1885 15 R. M. Leavenworth, Kansas 5o Dec. 2, 1885 16 L. H. Chicago 47 May 8, 1886 17 A. C. Chicago 51 June 24, 1886 18 R. L. Dubuque, la. 64 Oct. 23, 1886 I9 E. W. Aurora, Ill. 50 Feb. 14, 1887 20 R. S. Chicago 40 Feb. 22, 1887 21 J. L. Chicago 38 March 10, 1887 22 E L. T. Walkerton, Ind. 42 Dec. 21, 1887 23 E. K. Chicago 40 April 30, 1888 24 I. J. Chicago 64 May 3, 1888 25 A. E. W. Oskaloosa, la. 57 May 22, 1888 26 M. M. Fort Wayne, Ind. 54 July 14, 1888 27 J- H. Evanston, Ill. 55 May 17, 1889 28 E. J. Chicago 42 July 29, 1889 29 E. P. Chicago 49 Oct. 29, 1889 3° L. M. W. Waverley, la. 65 Nov. 8, 1889 High Amputation of the Uterus for Cancer. TREATMENT OF UTERINE CANCER. 7 Result. Remarks. D. Death on sixth day. R. Died eight months after, from recurrence of disease. R. Recurrence in four months. Date of death not known. R. Had a child two years later. Alive and well in October, 1889, six years and two months after operation. R. Was "perfectly well'' June, 1887, three years and seven months after operation. No later history. R. No symptoms of recurrence Nov. 1, 1889, five years and nine months. R. Recurrence in eleven months; death in fifteen months. R. Recurrence in two months ; death in four months. D. Death on fifth day. R. Disease recurred in parametria. Death four and a half months after operation. R. No recurrence. Health good August, 1889, four years and three months after operation. R. Subsequent history unknown. R. No return ; health good four years and two months after operation. R. Well and free from recurrence four years after. R. Well February n, 1886; no later report. Recurrence in five months; death in eight months. R. R. Death in nine months from recurrence. R. No recurrence three years after. R. No recurrence Nov. 1889, two years and nine months. R. Well and free from return at end of two years and eight months. R. No return. Health good two years and seven months later. R. Recurrence in four months; date of death unknown. R. Recurrence and death in six months. R. No recurrence in Sept. 1889. one year and three months. R. Died three months later. R. Recurrence and death nine months later. R. Disease not all removed ; symptoms continue. R. Symptoms of recurrence at four months. R. Too soon to know remote result. R. Too soon to know remote result. 8 prognosis of an operation, it should not deter from ah attempt at removal of the disease in any case in which removal may seem feasible; and it should admonish us to be as thorough in operating as may be consistent with the immediate safety of the patient. Cauterization.-In The Lancet of August 2, 1884, there was published an abstract of a report made by Pawlik of 136 cases of cancer of the cervix which had been treated, at Vienna, by means of the gal- vano-cautery. The report embraced a period of twenty-three years. Of the entire number, 10 died soon after the operation, making a mortality of 6.6 per cent. Of the 126 survivors, 33 were in good health and free from recurrence at periods varying from two to twenty-one years. At the annual meeting of the American Gyne- cological Society, held at Boston in September, 1889, Dr. John Byrne, of Brooklyn, read a paper embodying a report of 367 cases of uterine cancer treated by the galvano-cautery, the observations ex- tending over a period of twenty years. The cases being classified according to the portion of the organ affected, the vaginal portion of the cervix was involved in 59, the entire cervix in 81, both cervix and body in 219, the body alone in 8. The mor- tality of the operation was less than 1 per cent. The period of exemption from recurrence varied greatly according to the anatomical seat of the disease, being greatest in those cases in which it was con- fined to the vaginal portion of the cervix, and least in those in which the corpus was alone involved. JACKSON, TREATMENT OF UTERINE CANCER. 9 In 36 cases of the former which were kept under observation, the average period of freedom from return was eight years and seven months, 30 re- maining well over five years. In the 8 cases in which the corpus was alone diseased, the average period of exemption was two years. In more than one-half of the entire number of cases treated there was freedom from symptomatic return for from three to eighteen years. Hysterectomy.-The removal of the entire uterus for cancer has been performed probably not less than 1200 to 1500 times. At first the organ was removed by laparotomy, but the operation was attended by such a frightful mortality-not less than seventy-two per cent. -that it is no longer done when the vaginal method is feasible, the latter being vastly safer. Dr. Sarah E. Post has compiled some extremely valuable statistics bearing upon this point. In the American Journal of Obstetrics for 1887, she published a table comprising 722 cases, and showed that the mortality of the operation was twenty-four per cent.; and, although the statement that the death-rate is steadily diminishing is probably true as applied to a few operators who have had excep- tionally large experience, it is hardly true concerning the great mass of operators. Indeed, I have no doubt that if all the cases were published, it would appear that the mortality of the operation is now, and always has been, considerably over thirty per cent. But, accepting the published statistics as correct, the mortality of hysterectomy, as compared with partial amputation, is four or five times greater, 10 and as compared with cauterization, eight or ten times greater. However, the advocates of hysterec- tomy claim that, as a compensation for this greater death-rate, the disease is much more likely to be wholly removed, and thus freedom from recurrence, and prolongation of life more certainly secured. The apparent reasonableness of this claim cannot be denied, but, unfortunately, observed facts, now in great number, show conclusively its fallacious char- acter. For example, in 1886, Dr. Post presented a table showing the results of 137 cases; 40 of the patients died-mortality 29 per cent. Of the 97 survivors, only 18 were alive at the end of eighteen months to two years. In Pawlik's 136 cases-one less in number-with a mortality of 10, there were 33 alive and well at from two to twenty-one years. Hofmeier, in the report already referred to, of 96 cases of partial amputation, compared the late results with those in 33 cases in which the entire organ was removed. While 19 of those in whom partial am- putation had been done were alive at the end of four years, all the others were dead. In Fritsch's 60 cases, with 7 deaths, only 2 were alive after three years. Terrier has recently reported 18 cases. There were 4 immediate deaths ; in 3 cases the dis- ease could not be removed, and of the 11 who re- covered, only 4 were free from recurrence at the end of two years. At the last International Medical Congress Martin reported the subsequent histories of 214 women who had survived the operation. Of these, Leopold had 42, Schroeder 46, Fritsch 60, and Martin 66. Of JACKSON, TREATMENT OF UTERINE CANCER. 11 all this number only 5 were alive after four years. Hence, we may say that the successful removal of a cancerous uterus is a very different thing from the successful removal of a uterine cancer. Having considered the relations which each of the three prominent methods of dealing with cancer of the uterus sustains to the questions of immediate mortality and remote results, it is not difficult to fix their status. Partial amputation is doubtless a beneficial pro- cedure. With a low rate of mortality, probably not exceeding 5 or 6 per cent., it has in many cases re- moved the disease permanently, and in others stayed its progress and prolonged life. In a still greater degree actual cauterization has been shown to be potent for good. The recently published results obtained by Dr. Byrne are wholly without parallel, both in the extremely low death- rate and the greatly prolonged immunity from dis- ease. Dr. Byrne's report is unquestionably by far the most favorable showing that has ever been made concerning any method of treatment for uterine cancer in any considerable number of cases ; and as such it distinctly challenges our considera- tion. Hysterectomy is a ghastly failure. Not only has it given worse results, both immediate and remote, than other methods of treatment for cancer of the uterus, but I affirm that it is worse than no treat- ment at all. A hundred women with uterine cancer will live a greater aggregate of years if left alone than if subjected to hysterectomy. 12 TREATMENT OF UTERINE CANCER. And now, as candid physicians with an honest appreciation of the duties we owe to our patients who place their trust in our integrity as well as in our skill; as men and women willing to be guided by the logic of facts rather than by our predilections or falsely found preferences, what should be our atti- tude in this matter ? If we desire to secure the best interests of a patient suffering with uterine ca-ncer, what method of treatment should we choose for her? Should it be one which with the least risk promises the greatest length of life ? or, one which with the greater risk promises the shorter period of immunity from disease and death? THE MEDICAL NEWS. A National Weekly Medical Periodical, containing 24-28 Double- Columned Quarto Pages of Reading Matter in Each Issue. $4.00 per annum, post-paid. The year 1890 witnesses important changes in The Medical News resulting from a careful study of the needs of the profession. Its price has been reduced, and its bulk also, though in less proportion. The mass of information, on the other hand, has been increased by condensing to the limit of clearness everything admitted to its columns. Three new departments have been added to its contents-viz.: Clinical Memoranda, being very short signed original articles, Therapeutical Notes, presenting suggestive practical information, and regular Correspondence from medical centres. Hospital Notes will detail the latest methods and results of leading hospital physicians and surgeons. Special articles will be obtained from those best qualified to write on subjects of timely importance. Every avenue of information appropriate to a weekly medical newspaper will be made to contribute its due information to the readers of The News. The American Journal of the Medical Sciences. Published monthly. Each number contains 112 octavo pages, illustrated. $4.00 per annum, post-paid. In his contribution to A Century of American Medicine, published in 1876, Dr. John S. Billings, U. S. A,, Librarian of the National Medical Library, Washington, thus graphically outlines the character and services of The American Journal : " The ninety-seven volumes of this Journal need no eulogy. They contain many original papers of the highest value; nearly all the real criticisms and reviews which we possess : and such care- fully prepared summaries of the progress of medical science, and abstracts and notices of foreign works, that from this file alone, were all other pro- ductions of the press for the last fifty years destroyed, it would be possible to reproduce the great majority of the real contributions of the world to medical science during that period." COMMUTATION RATE.-Postage paid. The Medical News, published every Saturday, I The American Journal of the Medical > in advance, $7 50. Sciences, monthly, . . . . .1 LEA BROTHERS & CO., 706 and 708 Sansom St, Phi I a.