REPORT

Of

co ITTEE on THESIS

The undersigned , acting as a Contlittee of the Graduate

School , have read the accoz:zpanying thesis suboitted by

Janes 'fells Ross , for the degrae of ~aster of cience

in Surgery. They approve it as a thesis oeeting the re-

quireoents of the Graduate School of the University of

innesota, and recoD?lend that it be accepted in partial

f'ulfilloent of the requireoents for the degree of laster

of Science in Surgery.

ru_(). -- ---------------

__ :k£_~------

;-ru4~~- (

4- 21 6M

THE UNIVER ITY 0 'I ESOT

G DUATE SC.iOOL

Report

of

Co ittee on Exa !nation

Th1 is to ccrtif t e the

un ers1gned, as a co ra

S""hool, h ve ven J

final oral e m nation or r e o

t r of ci nc in ur ery

e recomm nd t

be conferred on

of ur

4-ZI 6M

THESIS

CARO moMA. OF THE C.EliVIX UTERI A CLINICAL STUDY WITH A SOO~RY OF TH~ ~ULTS OBTAlliED

BY VARIOUS METHODS OF TR.EA T

Jaoes Wells Ross, • B. '

Suboitted to the faculty of the Graduate SChool of the

University of Minnesota in partial fulfilloent of the require-

Dents for the degree Of Master Of SCience in Surgery.

IJarch, 1922.

f f ff t t f I (ff I 1 1 f (ff If C f I I I If I( I t C ti I f f I 1 t f ff f

f f I I f f I I f

.. ' .. ' ' ,, ' .. flf I If

' ' ' "

•'• ,,, •' . ·:·

'•'.

In order to esticate the relative values of various forcs of

treat:cent in cancer of the cervix, a study was :ca.de of 475 oases seen in the

Meyo Clinic between January 1, 1913 and Dece:cber 31, 1918. The latter date was

chosen to provide a period of at lea.st three years sillee the patients were first

seen at the Clinic.

The subject is one of great iJ:Iportance for ca.mer of the cervix

still takes its toll in spite of all our efforts. It is the oost frequent forc

of ca.no er in the fecale, coJ:Ipris :ing 29 .5 per cent of all types foul'.ld. in wooen

(Welch) and 81 to 86 per cent of all genital ca~er in this sex. As carcinor:ia.

of the fundus is cooparatively infrequent (3 per cent - 10 par cent of uterine

cancer) and as it is cOJ:Ip&rativaly readily reooved, cancer of the cervix be-

comes of even greater significance. When we c ansider that a larger nuober of

WOilen died of uterine cancer during the year 1918 than the nuober of cen of the

AI:lerican Expeditionary Force, killed in the recent war, it behooves us to cake

every effort to deal core efficiently with this disease. One cannot help being

iJ:Ipressed, in reviewing this series and the reports of various oen the world

over, with the iz:portanoe of bringing before the public the value of ear:cy

diagnosis. With this type of ca~er especially, in earl· treatcent alone lies

the only hope of cure. Often cooing at the oenopause when disturba~es in

I:lenstrua.l function are apt to be disregarded alike by patient and physician, and

when the sycpto:cs are difficult to interpret, it will be only when all wocan at

this period of life insist on thorough periodical exa.:cinations, that we oay

hope for success in treatoent. The active educational CSJ:Ipaign now being con-

ducted by the .Anerican society £or the Control of cancer has already begun to

accoJ:Iplish sooething. As el:Iphasized in the circular, published by this organ-

ization, our efforts oust not cause undue a.lam. The greatest factor 1n prevent-

! ing a patient seeking advice is fear of kn.owing the truth. If, therefore, we (\J

--2

can Offer the early case a high probability of cure with a low prica.ry oortality

and can teach this doctrine throughout the land, our success is assured. On the

other hand the profession :oust realize that it assur:ies all responsibility for

pursuing an expectant or indifferent course when accurate diagnosis is v.d. thin

the reach of all.

It then beoor:ies necessary to develop oethods of treatoent best . suited to individ'Ual cases. In this connection a knowledge of the uninterrupted

course of the disease and the conditions present in various stages, is of the

utoost inportance. Cancer of the cervix is essentially a local disease.Leitch

in a review of 915 autopsies on patients dying of this condition found bydroneph-

rosis in 75 per cent. He estioated the duration froo onset of syrzptoos to

death, at twenty-one oonths. Regional lyoph nodes were involved in only 38.36

per cent although this figu.re is probably too low if judged by collected statis-

tics of D~derlein. These patients die of oachexia and .urer:d.a. rather than ex-

tensive oet astatio cancer.

The radical abdooina.l opera tion;· ertheio hysterect~, undoubted-

ly carries a prohibitive oortality in the hands of oost operators. ls it not

then in the interest of the patient that we seek an index of the rate of exten-

aion of the disease ind subject only those patients to extended hysterectocy

who have highly ca.lignant tmors and for whoo prognosis of ultioate cure is

poor? Cure is then indeed a triuoph.

Froo the past, the cautery and the knife have cooe down to us

as recognized agents in treatoent although a oultitude of "cures" have been

suggested. ·ore recently radiuo has been introduced, and high voltage - B:3.y

therapy. Reports of results obtained by nany observers usi various oethods

are confusing and this is due chiefly to the fact that the esticated stage of

the disease is subject to the personal equation of the observer . The effects

of radiuo r.ia.y be subject also to variation with the dosage, and oethod of

4-21 6M

- -3

application .

In 1912 J. F . Percy brought forward a cethod of prolonged cauter­

ization by slow heat and cited cases which had reoained free froo recurrema for

periods ranging froo three years to eight conths . In 1918 ha reported sixty- five

cases, treated by this nathod, ten of whoo ware living froo two to nine years

after operation (15 per cent). A series of forty- three cases is reported by

Cole . These were all inoperable and ha astinates the average prolongation of

life at ten oonths . Seven had lived for periods up to three years and in all

a o elioration was obtained . Balfour in 1916 reported favorab~ regarding this

l.:lethod ecployed in inoperable cases . He foml.d carked ioproveoent but rry later

observations on these sane patients show that cure was effected in only two

cases so far as is known .

RadiW!l has oany followers . In 1915 Kelly and Bunlha.D., revie;ved

213 c ases (14 operable and 199 inoperable). They reported cure in fifty-three

Of the inoperable ones . The foroar believed that three out of every four cases

of apparently hopeless ca~er could be cured by Radiutl and opera tion . On the

other hand Graves, during June of last year, stated very definitely his opinion

that radiuo does not perI:Bllently cure . He believes that sooe inoperable cases

my be rendered operable and such patients cay live oany oonths only to die of

recurrence . But in the treatoent of recurrences he believes tha t Radiutl offers

nore than any other oethod . He had one patient treated with ra.diUJ:l who lived

three years and one now living six years after recurrence . In cases favorable

for surgery he does not feel justified in substituti radiUI::l . Bailey also

obtained. good results but the tine is too shOrt in whic1. to judge the outc a:ie .

In a recent paper Clark was extraoely enthusiastic with regard to

the effect of radiutl . Of 214 cases of inoperable ca re inoca. of the cervix,

twenty-five had passed the three year period {ll . 6 per cent} and forty-one others

were living, all over a year since treatoent • Only nine however had lived five

4-21 6M

- -4

years. In the sane journa 1 Dtmean and Schoi tz have published encouraging res ul ta ,

These operators are using larger doses than was the custoo at this clinic durillg

the period covered by the present review. Clark also inserted radiuo needles

into the base of the broad and utero-saoral liga.oents, a procedure which has not

been carried out here. Our irnediate results have been encouraging lli m .fil:!§.­

tained. in the curative sense. However it is to be hoped that,when sufficient

tioe has elapsed in which to judge the results of treatoent during the past

three years, a definite increase in the nuober cured will result .

In the present series ra.diuc was used i i oper< ble case

in :cost instances. These patients received vaginal and intracervical applica­

tions of about 700 og . hours (50 og. for 14 hours) repeated. three or four til:les

in the course of ten days, with usually one or two rectal treato.ents of 100

ng. hours. They returned at intervals of two to three nonths and received sio­

ilar doses. Now, however, bare raa iuo tubes (wall o.6 co. silver) are inserted

within the cervix and uterine canal after the redundant grcmth has been reduced

by radiation if necessary. The dose 700 to 3000 cg. hours (sulphate) in favor­

able cases is gi van at a single sitting and a total of 9000 to 12000 og . hours

is gi van within a period of three weeks. X-Ray is used in addition but e have

not yet tried the high voltage oachine . results then, J:IUSt not be considered

as the final conclusions of this Clinic relative to Radiuo and non-opar~t ive

treat:o.ent .

Froo reports of various authors it would saeo that the wertheio

hystereotooy in operable cases offered the best prospect of pem.anent cure .

Graves in 101 oases had six operative deaths and 27 . 6 per cent of five year

cures, with an ultimte cure of 16. 6 per cent . Still oore recently Bonney in

100 cases reports a five year cure in 50 per cent of the eighty who recovered

froo operation or 40 per cent of the total . Including inoperable cases he bas

then 26 . l per cant of five-year cures • . His percentage of oper~b ility is 63 .5

4·21 6M

-..o and agrees with that of Graves (64 per oentJ while his ir:icediate oortality has

been reduced to 6 per oent in his last fifty oases . Of a sinilar nature is the

report of Shaw but it is yet too soon to judge his results . He obtained ten

four-year cures in fifty-nine cases and 55 . 3 per cent of the patients wb:> sur­

vived the operation are living and well, all over a year after . He advocates the

use of radiuo to render operable, cases whioh otherwise would be left to pallia­

tive oeasures .

The operation eoployed here in cases of this series was in sooe

inst8ll0es a oodified 1ertheio although less drastic in the extent of the dissec­

tion than that operation as originally advocated . In other instc.J10es a i::ruch mre

conservative procedure was carried out . These facts are apparent in the low oper·

ative oortality. A cuff of vagina well beyond the growth was re:coved and as

z:zuch of the paraDetrial tissue as was deaned advisable . The ureters were freed .

The interval between cautery and hystereotoc.y givingoost favor­

able results was one nonth, and cost patients operated on after a greater lapse

of tina did not obta in p eroanent relief . It is generally conceded that hyster­

eotol:ly following r adiuo treatnent should be perfo~d after froo two to four

weeks. This interval allows cellular destruction to take place and antecedes

fibrosis. Only one case herein reported ,which lived eight oonths ,was radiated

prior to opera tion (one oonth prior) although this procedure is now being

carried out in practically all operabl9 cases. Vaginal hysterectooy as done by

the ala.op and cautery nethod.

In this review are considered 475 c anseouti ve cases. There ere

in addition eight cases of carcinor.ia in the stuo:p of the cervix follo 1ng hyster­

ectony and seven lm.treated cases coilprising ex.:plorations , excisions of spec iJ:lens

and s iople currettage which are not considered .

are living.

4-21 SM

one of these fi~een patients

- 6

Of the 475 patients considered, sixty are living (12 . 6 p r o t) .

All of these have therefore lived for over three y rs . It is known that 322

are dead. There were four operative deaths, one after si le cauter , t o after

Percy cautery and one a hystereotooj· aftor ercy cautery. The length of life

up to Jan. l, 1922 is lmown in the case of 347 patients living and dead .

are the ones with which we are oost caooerned (Table A Colurm 3) .

ese

The cases are arranged in five groups. In so doing personal

error is adoitted as the grouping 13 based on the history of the clinical and

operative findings when the latter was available . Group I conta ins the e ~

oases in oost of which :cioroscopic exaoination ~s neces ary to est lish a

diagnosis . In Group II are cases whic oay be c idered operable, ith no

extension t o the vaginal wall, a ooveable uterus and little or no thickening

of the broad liga.oents . Group II c a:zprises cases hich t be con.sider

operabl e were it not for extE1IU1ion t o the alls of tne v 1.na. Group Ill con­

t a ins inoperable oases as deteroined by fixation una. i iltr t io of the br

ligaoents . Group IV is oade up of advanced ca ses, with b er or root l 1 -

volveoant .

There were thirty-three DO es of tre toent de ndin on ri tiona

in technique as for exaople in the use of the el"Oy autery hether or not t e

abdooen was opened and whether hyster too as er or ed i i a tely or t a

later date. '..I: ese various oetnod.s a.re grou una.er four in he 1ll8 , ur r

.Radiuo, el"Oy cautery and Sillple Cauter-• 1th s -he 1ngs in.die ti c !n­

ations oft o or oore (able I - Table IV).

Several f:;.c tors ere c oa:ion t o the series. The average a

practically the saoe for all groups (forty-eight ears) that for r Ill

being forty-seven and for Group II, forty-nine ·ears. e ·oungest patient s

twenty-three and the oldest seventy-two. All but eleven ere rried d had

borne on an average, four children. mhe age of the yo.mgest child w on the

4- 11 •M

~ !:! .. Table A 3:

ABBREVIA'YBD GRJU!- ING OF CAS.r;S

Grouping T6tul Cnses in which Dead Livini; 11wnber len{;th of life over cases is known 3 vrs .

Group I Enrly 65 51 26 27

Group II Operuble 142 104 91 24

Group IIA Inoperable on 87 62 64 5 nccount of ex-tension to vugina

Group III Inopero.ble 146 105 112 4

Group IV J~dvnnccd 36 25 29 0

Totul of nll P.:rouvs 475 347 322 SC

Lived Lived Died over over under 5 vrs . 4 yrs . 1 r .

11 25 4

17 26 26

5 5 28

1 2 58

0 c 21

34 58 137

Averui;e length of life

3 yr . 7 mo .

2 yr . 8 r

1 yr . 8 l:lO .

1 ~ r . 1 ri.o .

7 mo .

I I

-:i

----II f' :: .. Tuble 1 . I

RBSULTS OF VARIUUS :F\)RJjS UF '£REAT.M.".c:I! T IN GROU1- I.

Treutrrcnt Total De i..d Cases in uhich Living Li-ved Lived number length of life over over OVf:>r ca.soi; is lmown 3 yrs . 5 yrs . 4 yrs .

I . Surgery 20 9 16 7 6 9 (~J flus s~~plo cnutery 5 1 5) 4) 2 3 (b) 1 lus rndium 11 5 10) t..i) 0 5 ( c ) flus s im}-le cu.ute~· ) 28 ) 15

~.nd rudium 4 2 4) 2) (, 2 (d) .t lus Fercy co.utory 10 4 6) 2) 1 2 (e) llus lercy cuutory ) )

and re.di.um 3 2 .:>) 1 ) 1 2

II · Rudi.um only 5 1 3 2 0 0

lII . I-ercy cuutery 3 2 2 1 1 1 (e. J rlus radium

IV . Si..'T-ple cuutory 1 0 0 0 0 0 (o.) 1 luG rudium 3 0 2 2 c 1

Totu l 65 26 51 27 11 25

Died under 1 yr .

0 1 0

0 2

0

0

0

0 0

3

Averar;e length of life

yrs . mos .

4 1 4 0 4 0

3 9 2 3 . 5

3 5

2 7

4 0

3 11

3 7

I I

O>

N

To.ble 2 .

RESULTS tJF VARIOUS F\Jffi~ OF TRE.A.Tl~HT Ill' GROUl II .

Trentr.:ent Totnl Dcnd Ca~icc in \'Thich Living Lived Lived Died J.vcro.ge lenf!th numb:Jr lenE;th of' life ov :r over OV€T under of life Cl:lSOS is kr.ov:n 3 yr.., . 5 yrs . 4 yrs . 1 yr . yrs . mos .

I . Sur ii;ery 26 15 *24 *9 11 *12 utcry 9 7 9) 2) 1 1 1 2

6 4 6) 2) 0 1 u 2 3 . 5

le cuutory i;:3) 12 8 1 *4) 42 0 •l •l 2 8

(d) Flus 1~ercy co.utory 27 21 20) 4) 4 7 3 3 1 (e) flus rercy ccutcry ) )

e 3 •3) *1) 0 •1 *l 2 4

II · Rodium only Gl lti 17 2 0 1 8 1 6

111 · fercy cnutory 23 16 14 1 l 1 6 1 8 (n) flus rndium 2 2 l 0 0 (, 0 2 7

TV . Sir::~le co.utcry 3 2 2 0 (J c l 0 8 5 4 0 0 0 3 0 9

Toto.l 142 91 104 24 17 25 26 2 8

Table 2- A

RESULTS OF Vi RiuUS FDR1:J3 OF TRBA TIEB1'1 T IN GROill' II-A

Tre tment Totrl Dead Cases in i:r~iich Livin~ Lived Lived Died , ver· ge ler..gth nul!lber length of life over over over under of life

Ct SCS is known 3 yrs . 5 yrs . 4 yrs • 1 yr . yrs . mos .

I· Surgery 6 2 4 2 3 3 0 4 4 ... (a) Flus si.Irple cautery 4 4 3) 0) 1 1 0 2 11

(b) : lus rudium 1 0 1) 1) 0 0 0 3 11 (c) Ilus sil·ple cnutery ) 10 ) 3

and radium 1 0 1) 1) 0 0 0 3 0

,a, Plus lercy ca.utery 5 1 2) 1) 1 1 (, 3 9

( e) 1: lus i·ercy cuutery 4 3 3) 0) 0 0 1 2 2 . 5 and radium

II . Ro.dium only 39 30 26 0 0 c 15 1 0

III · Percy ca.utory 12 11 10 0 0 0 4 1 8

(a) I- lus radium 2 1 1 0 0 (, c 3 6

IV . Sin.; le cautery 6 5 5 c c 0 3 1 2

(a) Plus radium 7 7 6 c 0 0 5 0 10

Total 87 64 62 5 5 5 28 1 8

I

~

i1 Table 3

. I

RBSULTS OF V1 ::.nl1US ?Gmrn uF TRE:-.. 'l'l.:::,1 1 T IN GRUUl

Trent:ment Totnl Deu.d Ct:ses in which Living Lived numbc,r le':lgth of life over ove r er ses is kno;rn 3 yrs . 5 yrs .

I· Surgery 3 3 3 0 0 (a) llus sir.ple cnutery 5 3 3) o) 1 (b) 1:- lus ro.dium 7 5 6) 1) G

(c) Ilus siq le ca.utcry ) 16 ) 1 and radium 1 1 1) C) 0

(d) I'lus 1 ercy caut ery 5 5 5) c) 0 (e) llus l-ercy cautery

\ ) )

and r ed ium 1 1 1) 0) c

II . Radium only 57 42 40 2 0

Ill · lercy cautery 32 25 22 0 0 (a) l lus radium 11 9 7 c 0

IV . Sir , e cuutery 9 8 7 0 0

( a ) l lus r adium 14 10 10 1 0

Toti' 1 145 112 105 4 1

III .

Lived Died over under 4 yrs . 1 yr .

0 1 1 0 0 2

0 0 0 2

c c

1 22

0 17 0 3

0 5 1 7

3 59

Avon ge length of life

yrs . mos .

1 7 3 0 1 6

2 6 1 7

2 6

1 1.5

0 8 . 5 1 2

0 8 1 3

1 1

I I I-' I-'

T::.ble 4

lESULTS uF V.lRIOUS FDRI:S OF TRE!.'l't:ENT DI GRODI rv.

Tree tment Totri l Dead Cas e s in ·:rhich Living Live d Lived number length of life ovor over over cusc s is knosn 3 yrs . 5 y rs . 4 y rs .

I · Surgery 1 1 1 c 0 0 (a.) I 1 us f ercy c o.u tery

and radium 1 1 1 0 0 0

II . Radium only 11 8 5 0 0 0

III. Fercy c~utery 11 9 9 0 0 0 (a) Plus r · dium 2 - 0

rv . Sir1le C~\Utocy 7 7 6 Ci 0 0 (a.) 1- lus r udium 3 3 3 0 c (l

Totnl 36 29 25 0 0 0

Died under 1 yr .

1

1

3

8

5 3

21

Ave1·ge length of life

yrs . r os .

( ' 11

(.. 10

0 9 . 8

0 6

(, 7 c 5

(, 7

I I I-' l\.)

- 13

average sixteen years . Two of those Ullilarried are still living. In twelve in­

stances the onset of syoptoos occurred during pregnancy and two of these patient

are living. Microscopic exaoinat ion was recorded in 277 cases . Of these 249

were squaoous-cellad oarcinona. and twenty- eight ad.enocarcinoca. . The preponder­

ance of the foroer , 89 . 9 per cent, is slightly higher than that given by Oge.ta.

(87 . 7 per cent) .

If we consider as operable the cases in Groups I and II our per-

centage of operability will be 44, which is sH1ewha.t lower than those of Bonney,

Graves, Cullen (50 per cent) and others . If we include cases in Group II A the

percentage is raised to 62 . sooe c c..ses in this latter group proved opemble

(Table IIA) .

The average duration of syoptoos before the patient sought ad.vice

shows a gradual increase in the successive groups . In Group I it was 4 . 6 nonths ;

in Group II , 6 . 7 nonths , in Group IIA. 6. 8 oonths , in Group III 7 . 6 oonths and in

Group IV, 11 . 2 oonths . This illustrates how a short delay oa carry a patient

beyond the possibility of operative aid . In fifty-two c~ses there s a dela•

due to failure on the part of the physician to recognize the condition . Thi

deoonstrates two things . First, the fact that the disease a s sufficiently ad­

vanced in nost cases to be recognized and second, that a diagnosis was not tnde

and should have bean, in certain cases. hese patients lost on an average s 1x

nonths of valuable title which oight have bean saved for thfD had a biop Y been

?:la.de. Herein lies the responsibili t of thd profession.

In reviewing the results, the norm.1 death rate for wooen of

this age oust be borne in oind(42 . 9 for the nine years) . The foregoing tables

will be of a sistc.nce in enabling the re~der to understu:i.d the results obtained.

In any group the nur.iber troated whose spa.n of life is known, the nuober surviv­

ing four and five years, :-.nd the nuobar who died early (within the first year}

serve to shcm the efficacy of the various treatoents . If , therefore, under a:n:y

•-21 SM

--14

given treatoent we can show a large nuober of patients who lived four and five

years and a sna.11 nunber of early deaths• I think it will be conceded that this

traatoent is of distinct vaJne as cor.ipared with one showing the reverse.

In sooe instances the diagnosis of carcinoca was not confimed

I:licroscopically but all were clinically I:lalignant . This awlies oore especially

to the case of patients treated by Radifltl in the earlier years . s in sooe who

died. the nature of the growth is not known, and it was itI,POssible froc replies

received to establish whether death was due to ca~er or other causes. it is

reasonable to suppose tllat in sotle now living and on whoo we have no I:licroscopio

findings , cancer was present . In the case of those living we have positive

diagnoses in all except seven cases . An analysis is shewn in able V. I have

exatlined the tissue rerioved in it>rty of these and atl indebted . to Dr. Broders for

confircation of oy findings . These specitlens were studied fro:c the histologic

standpoint to deterI:line if their structure contributed in any way to the survival

of the patients concerned . The epitheliocas were graded I , II , III and IV on

the basis of Broder's classification . Those showing no differentiation ere

placed in Grade IV. {here any differentiation was present the tur:ior was placed

in one of the lower grades . Vhere differentiated and undifferentiated tissue as

present in equal aoounts Grade II was established. It as noted that 63. 2 per

cent fell in Grades III and IV and none in Grade I . There were siX in Grade II

(16 . 6 per cent) twenty in Grade III {55. 5 per cent) and ten in Grade IV (27 . 7

per cent). Of the four adenocarcinol'.lb.s one was of particular note 1n that it

showed a :carked degree of :cetaplasia. Phota:iicogra.phs of typical sections are

1hown . Frori these findings it is apparent that even in the case of patients

who survive, the t1.D0r is usually 0£ a very I:lalignant type and hence cocplete

destruction of the growth oust be accoopl ished early in order to obtain good

results .

4- 21 8M

---------------~-------

Table V. PATimTS NO''i! LIVING.

Treatoent Tice

Total abdoninal hyst ereot orq over 8 yr . II

II

II

II

Vaginal hystereotocy II

It

II

II

II

II

SiI:Iple cautery and later hysterectot\V II

II

II

II

II

SiI:Iple cautery and inl:lediate byster-ectocy II

Total abdor:iinal hysterectoey and radiuo II

II

Vaginal hysterectocy and radiuo II

Siq>le cautery and total abdotlinal hys terec tocy and ra.diuo II

Siq>le cautery and vaginal hysterectocy and radiur:i ti

Percy cautery and later hysterectocy 11

II

II

Percy cautery and inl:lediate hysterectocy" Percy cautery and Percy cautery and

~nd radi UJ:l

Perey cautery and and radi UJ:l

Ra.di uo only

Percy cautery only

vaginal hysterectooy " later hysterectocy

" itltlediate hysterectocy

II

II

II

II

II

Sinple cautery and radiUJ:l " II

• - 21 OM

6 II

5 tt

4 It

3 It

8

7 It

6 tt

5 II

4 II

3 II

8 II

7 II

5 II

4 It

3 tt

3 ti

4 It

3 "

4 "

3 It

4 " 7 II

6 II

4 II

5 II

3 II

4 It

5 It

4 3 II

6 II

7 II 4 II

3 II

Cases 3 l 3

l l 2

l 2 2 l l l 1 1 1 l

l 2

4

4

3

3

2 2

1 1 1

1

1 1 5

1 1 2

l

- 15

Clinical Pathological Group findings II All ll • I!A II 2 II l I I II 1 IIA 1 II I 2 I 2 I II II I I I II

I I l II l I l IIA l III 1 II l I 4

II 2 I.IA l

I 2 II 1 II 2 II 1 IIA l I I II 1

II

I II I l I l II 1 IIA l IIA l II

! 1 IIA l I

E

Ca. .

A Ca . .... both ..B both E

2 2

both

both

both

A a .

no s pee ioen

no specir:ien II

.... no spec icen A Ca . no specicen E

specirlen # no .. no speci:cen ~

* One had cautery and radiuo for recurrence # RadiUil for recurrence.

--16

The length of life under various treatoents brings out several

interesting facts (Table VI}. The percentages, however, are based on nUilbers

z:m.ch too sll9.ll to render theo of value other than cocparative . It will be seen

that the efficacy of vaginal bysterectooy in certain oases is indisputable . Of

the nine living patients treated by this oethod cost belonged in the earlier

groups {Table V}. One, however, had extension to the vaginal wall (Group Ill)

Another point well illustrated, if we accept the supposition that sioilar

nuobers of tuoors of like potentialities are present in the various oinor groups ,

is the fact that delayed hystereotooy gave better results than 1.ocediate hyster-

ectooy in conjunction with both siq>le and Percy cautery. Furtherwre , abdon-

inal hystereotooy and vaginal bysterectooy, when supported by radiUil gave alco t

identical results which were apparently slightl better than either agent alone

produced. Ra.diUil as a oeans of obtclning pettianent cure was disappointing.

Of 133 cases so treated only six are known to be living. In justice to radiuo,

however, nust be considered three living patients treated by cautery and rad.iw:i.

These results oust not be given too ouch weight nor used to condecm the oethod,

for the cajority of the patients obtained ine tina le relief whic could not

have been given by any other oeans, and the dose used at that tioe was found to

have been too stlall . Henorrha.ge was controlled and discharge dioinisb.ed. or at

least rendered less disturbing, although pain hen once it becaoe establisned

was not influenced to any great extent.

The Percy cautery proved its elf cw·ati ve in only two early

cases, although palliation was effected in the reoainder as cited by Balfour

in an earlier review of swe of these.

4-21 SM

i I Table 6

L '.GTI-. OP LI?E u1mER VARil u~ TR&.Tl',wi . T IN .r-1-11 GRuuI S . . s.... s....

Ul :>.. s:: Ul :>. s:: Q) b.O l!) t-: rJ) b.() ti:) ;:;: s... s... s:: 0 !--4 ~ 0 Q)

;::s ·.-1 ~ .Ll ;::s ·.-1 .;..) s:: 0 ? 'd 0 i> 0 ? s::,:..; ..s::: 0

Q) b.O ·.-1 0 ·.-1 Q) ~ Ill.;..) (1J s:: s:: • rl 0 fJ) • rl 0 Ul "d Ul

Q) :;I Q) ~ ·.-1 s.-. (]) I-< Q) "d Q) s..

Hethod Ul 0 Cll 0 t> :>. ;:.: s.. s... ?-. ;:; s.. s.-. .;$ ? >. d s... CiS >! •.-1 0 Q) ;::s 0 Q) ;::s Q) ·.-1

Q.;..) o~ ,_:i l!) s:.: µ.. 0 t-') s:: ,.i.., 0 Oriti)

Total abdominal hys terectox:y 25 24 9 7 30 .4 9 39 .0 4

Vaginal hysterector.:.y 29 23 9 7 3c . 4 9 39 . 0 4

\.mputetion cervix 2 1 0 0 0 1

Simple ca.utery und lo.ter hysterectomy 15 12 5 3 25 .0 5 41.0 1

Simple cautery o.nd i.rnrr.ediate hysterector:w 8 8 1 0 1 12 . 0 2 Total abdomin~l hysterecton-y und radium 15 14 6 0 * 6 4.3 . 0 c Vaginal hysterectomy and rudium 10 ~ 4 (; 4 44 . C 1 Simple cuutery and totul abdor~inal (', 6 3 0 3 50 . 0 1 .,

hysterecton~ o..~d radium. Simple co.utcry and vuginul 5 4 3 (. 3 75 . 0 1

hysterectony and radium fc rcy cautery and l ater hystorectory 31 25 5 4 16 .0 5 20 . c 5 fercy cuutery nnd il:T..edia.te hysterectox:y 13 6 1 1 u; .c. 1 16 .C c I ercy cuutory nnd vugi nu l hystcrectol'cy' 3 2 1 (; 1 5C .~ 0

l-ercy co.utcry 1.1.nd lo.ter hysterector..y 7 6 1 0 1 lo . Cl 2 e.nd radium

.l:'ercy co.utery o.nd iimnedio.te h;rsterectocy 10 5 1 0 1 2C .o 0

and ro.dium Ro.diurn only

1 ~., ~l 6 c 6 1:; . 7 4 vv

rercy cuuter y only 81 57 2 2 3 . 5 2 ;:, . 5 3

Fcrcy cuutery u.nd r udium 17 9 (. - 0 1

Simple cuUtl ry 26 2.0 c - 0 0

SiL:,le co.utery nnd rndium 36 25 7 - 0 12 . 5 0 v

Tota l 475 347 60 24 'f . G 57 16 . 6 3

ercentages in this ti.hle c.re bnced on "Cases l:no::n11 • They thus f avor srr.ul l groups and those vrherein u large nUJ1,ber are excluded on account of insufficient do. ta .

I

* Ro.diun was i'irct used here i n 1016 I

f-J ~

'f

- 18

Your attention is now called to Table I ( · rly cases}. It will

be noted that twenty cases in Group I were tre~ted by surgery alone . Infon:w.tion

relative to length of life or whether living or dead, is lacking in four instanc•

es . Nine aro known to be dead, seven known to be living , and no patient died

within the first year . e have , than , infon:iation concerning sixteen pa tients .

Six lived five years and nine lived four years, the forcer being included in the

latte r . If we coopare these figures with those in the corresponding colm:ms

under Ot!l.er oethods of treato61llt and consider the degree of involveoent indicated

by the group , we oay arrive at a fairly accurate estioate of the relative va lues

of the oethods used in different stages of the disease. (Tables II , I Il , IV)

he point my be raised that these cases are not accurately

grouped, else wcy do we find any c :...ses in Groups I and II tNo.tad by other ca

than surgery . On account of factors s'IJ:)h e.s obesity, cardiac deco ans tion, and

the personal considera tions of the petiant, sooa a~rly c~sas ware trea ted by

radiuo. On the other hand, the probable accur....cy is borne out by the graduall

increased :cortality, the sb)rter period of life, and the longer duration of

syoptoos in the higher group •

he individual groups ce,:1 now be considored. a average length

of life of a few patients treated by a particular cethod ceans var little, but

if the nuober also be taken into consideration this avora.ga nay give soce idea

of bat was accooplishad.

Of the S.even cases in Group I ho lived over five ea.rs , ten

ere surgically tr a ted . o of the three treated by Eadiuc on wbDo we have

coJ:I,Plete data e.ra living and have lived thr3a ears . The t h ird lived one aDd

one-half yea.rs .

Both of those trea ted by siJlple ca.utery a.nd radiuo are living,

one three years and the other four yea.rs after treatoant . (In I:l3lt.ing a special

sub-heading fo r those receiving c~utery and radiuc, I ao reducing the nuober

4 · 21 IM

- 19

trea ted by radiUI:l reported by Stacy in l920) • It is tbl.s apparent that in these

very early cases the various types of treatnent gave sioilar results and it re­

tiains for tioe to prove the durability in those 1here1n radiuo was ecployed.

In Group II the Percy cautery and radiuo yielded appro.xioately

the sal:le early oortality. The forcer obtained. one five-year cure and the

latter one four-year cure . The coobination of radiuo, cautery, and surgery in

this group proved equally efficient to, if not slightly better than surgery.

The incidence of early deaths is higher but four of the seven are living hile

only nine of twenty- four wherein surgery sl ngly was used survive . (See asterisks

Table II)

Group I is of speoial interest . Of the five surviving patients

all received surgjcal or cor:ibined tr a.toent . The use of radiun as an adjunct

gave the best results while alone it s disappointing as a curative agent .

In Group III only cases receiving radiuo or radiun as pa.rt treat­

oent survive. Of those on hon the ercy cautery as used, seventeen of twenty­

~no died within the first year while of those on hon radiuo alone as used, only

anty-t110 of forty died in this period. In Group IV radiuo again sb:med a

light superiority in prolong life . Its palliative effect is universally

recognized .

one vesicosi

There 1ere twenty-one rectovagina.l, thirty-five veaic ovagi l, and

idal fistula, a total of fifty-seven in 418 o ses or 13 6 per

cent . The largest nuober :fbllO\Ved. Percy cautery but this oa • be due in part to

the f::..ot that the abdonen was not al 'lays opened to o c:mtrol the uterus and

esticate the degree of heat . The incidence is shown in able VII. It is

12 per cent in the entire series (476} and us two fistulae ere present in

eleven oases the percentage of patients 1th fistula would be 9 .7.

•·21 IM

Wt

-20

Table VII

Fistulas .

Recto- Vesico- Vesico-Treatnent Cases Vaginal Vaginal Sigpoid Total ercentage

Surgery 56 l 2 3 6

Sinple cautery and surgery 23 4 4 18

SUrgery and ra.di UD 25 2 2 4 16

Surgery and Percy cautery 47 3 2 5 11

Surgery, Percy cautery and radiUD 17 2 l 3 18

ad.iuo 133 8 9 17 13

Percy cautery 81 7 13 20 24 (high)

Sinple cautery and radiUD 36 l l 3

418 21 35 l 57 13. 6

leven patients had two fistulas which oakes the i~idenoe

9 . 7 per cent in the series (475 cases) .

4-11 6M

. {

• · 21 ...

--21

e my then o one lude :

l . That in very early o sq surgery alone gives good result •

That in oonbin.a.tion 1th radiuo surgery gives ali htly

better results than eurger alone.

That the ultitnte result in these oases tra ted b radiuo

alone is not lmcwn as only three ye rs has els sed.

II . Tb.at in sea surg ry alone or

oocbined with r diuo gives the be t results .

hat r iuo alone or ere cauter are both le s efficient

and of equal value . Hence uere ra.6.i

ercy oautery should be used .

is not available

I II • That in oases -"o""'p:..:::e.;;;:r.==.....:::=-=-"'~.:.;;-=-~...,;;.;==......;=-=~=

gives t e best results d raaiuo is disa pointing.

r

iv. ~at in inoperable oases radiuo lone or i coo ination 1th

oautory or surgery is the onl effeotiv ant .

v. T'na.t advanced cases r 1· i superior to 11 oth r

cethods but not cur ... tive .

VI • . ~ t the inoi~e ca 0 istula is er wit rerc c utery

than et od.

j( 1

2

BIBLI OG HY

1 . Anerican society for the control of Cancer: 11 .niat 1e know a out cancer " . Handbook published. by An. ed . ssn.

2 . Bailey, H.: :bdiun in uterine cancer. urg . , Gynec . & Obst . , 1916 , xxvi , 625- 631 .

3 . Balfour, D.C .: he treatnent bv heat of advanced cancer of the cervix (Percy ' s ethod} . oll . apers of the ~o Clinic , 1915 , vii , 378- 391: .

4 . Balfour , D. C. : Cancer of the uterus . Its surgical traa .. ont . oll . of the yo Clinic, 1916, viii , 452 61 .

5 . Bonney, v.: The radical abdoI.Jinal operation for cancer of the cervix. Brit . ~- • J . , 1921, o • .:il83, 1103- 1106.

Brcders , .c.: .., luanous call ::;pi thaliore. of the lip . hundred and thirty- seven cases . Jour • .AD . 656-664 .

study of five ed . s n ., 1920, lxx,

7 . Clark, J . G. a.nd Keene, • ~ ·: Irradiation in cencer of the fenale genito­urinary or ~ns . ~esults in three hundred d thirteen cases . Jour . t..o. ed . As n ., 1921 , lxxvii , Aug . 20 , o . 8 , Gl - 619 .

e. Cole, •• : Inoperable uterine c~rcinoos. treated by the colu cautery nethod of Percy . l. series of forty- three cases . roe . o • soc . ed., 1921, xiv, o . 6, 266- 260 .

9 . Cullen T . • : Cane er of the uterus . uoted by ing.

10 . ~derlein - KrOnig: Operative G~-n.akolo ie, eor hiece ,~ei zig l 20 .

11 . Duncan,

12 . Graves,

.: Uterine o cer with o serv~tions an result of treatcent 1th radiun in ore than three undred cases . our . ed. ssn ., 1921, lxxvii , o . 8 , 60 - 608 .

resent st tus of the treatnent of oper l c cer of t • e cervix . ·urg. Gynec . & Ob t . 1921 , xxxii , ·o . 6, 504- 08 .

13 . Kelly, H. ~ · and .ournao, ~ . ' .: iun in the treatr.ent o carcin s of t e cer •ix uteri ....nd v""t>ina . our . • 'ed . sn., l 15, 1874- 1878 .

14 . Leitch uoted by Cole .

15 . Ogata uoted by .schoff .

16 . Percy, J •• : _a results of tne treatoent of c cer of the uterus by tn.e o.otual cauter· with a. practical nethod for its application . Jour • .AD. 'ed . ssn., 1912 , l viii , 696- 699 .

4·21 SM

- 23

17 . Percy, J . F.: The end results of the treatoent of inoperable uterine oanoer by heat • .A:o . J . Obst . , 1918 , lxxv11 , 93- 102.

18 . Schoitz , H.: The treattlSnt of ca~er of the uterus . Jour . AJ:l . ·ed •• ssn. 1921 , lxxvii , o . 8 , 608- 613 .

19 . Shaw, .1 . F.: The pre""ent position of the trea.toent of ca~er of the cervix. Brit . M. J • , 1921, No . 3183, 1101- 1103 •

20 . Stacy, L. J .: ~e trea.tnent of carcinooa. of tne uterus by radiun. ed . Clin. ., 1919- 20 , 3 , 1 1 705- 706 .

21 . ·1eloh : ,Quoted by · ing.

22 . I ·, artheio, ~.: Le Cance~ de l ' uterus ' Col et corps; technique de l ' operation

et effic:Aite . Ann de Gynec . et d ' obstr . 1913, 2 s , x , 502- 506.

•·ZI IM

- 24

Replies received too late to be inc lud.ed. T i Il e

Group raa.toent T bulatod a Ye ( od

Va.5 inal hysterectoey unlmo 11 ving health a 3

I. Va.gi 1 hystereota::iy unlmo died 10

a.diun only unlmo 11 v:Lng 3 7

II . iople cautery unknown died 2 6

Sitzple cautery and rad.iml unkno ied 4

1 ple cautery and radiUD unknO died.lat operation lelsewnere

diuo only unknown led e

v nal hystereotoDy an~ ra.diUil unlmO living 4

icple cauter iDl:ledia.te a.bdoili-nal hysterec to d radiUil unknown living 4 10

Percy cautery abdooo opene followed later b total bd - Ul'lkllO 11v1 6

na.l bys t oreoto

III. 1cple c auto and. rad iUil unkno died 2 6

Total abdoDinal hystereot pr ceded and followed by r Ull unkllO n livillg 4 10

(r 1

ercy cautery unkn living(for r.- 6 e (curre •

illple cautery preceded b radiUD 1

diuo. onl unlmo d 2

-----------------------------------------------------------------------I le ca.utery allowed later

b v 1 hystereoto 0 •

ose ro lies er it a ther r cure to radi

ei t ear cure to v in.al hysterecto in ro r . e further establish

the value of hysterecto hen s o rt d b • radi or re oautery.

• · ZI 6

Fig. 1 (/100) o . 129862, s . ge 34 qu.aoous-celled. carcinoca of the cervix

Grz:.de iv • .;.ctive calls with no tendency to differentiation . atient living and well 5 yrs . 10 nos . after total abdoriin­a.l hysterectoey.

Fig. 3 (/100} ~o . 147230, .:.:rs . ge 62 Squa.cous-celled ca.rcinooa of the cervix Grade ii . ifferentiated and undiffer­entiated cells in atout equal propor­tions . ~atient living and ell 5 yrs .10 nos . after total abdor:Una.l

ig. 2 (/100 o . 166324, ge 47 SqUB.IlOus-celled c ... rcinoca of the cer­vix Grade iii - ctive cells th soal area of keratinizat1on . atient living and ell 5 yrs .4 nos . after caut ery and ia:iediate abdoc.inal ec too

ig. 4 . ( /50) • o . 245369, ·r .c . age 57 . .deno-carc inona of the cervix showing oetaplasia . ti ant 11 ving 3 yrs . 1 00

after va inal hy:> terec tocy . Has now a recurrence .