The diagnosis can not always be absolutely verified by removing with the scissors or knife small fragments of a suspicious erosion, as has been proposed by Ruge and Veit, since it is a well-known fact that it is often difficult to determine beyond a doubt the nature of a tumor as a whole, by microscopical examination of small particles of the growth.' I have always considered it justifiable, as I shall endeavor to prove when discussing the subject of treatment, to amputate the entire vaginal portion in these doubtful cases, even at the risk of having now and then performed the operation unnecessarily. We should never neglect to at tempt the cure of a suspicious ulceration, by the ordinary remedies and procedures, and if it show a tendency to heal, to cicatrize from the edges, we may be sure that it is not a commencing cancer of the uterus.
Now, while it is not easy to detect the initial stage of epithelioma, it is even more difficult to recognize carcinoma at its very beginning, when the deep-seated cancerous infiltration is hidden from view by overlying healthy mucous membrane. It is comparatively easy when the disease commences in the form of a few hard, isolated prominences situated be neath the mucous membrane. These can often be seen, even through a speculum, as little protuberances of a peculiar, deep bluish-red color. When the vaginal portion, however, is uniformly enlarged, and is smooth, hard and greatly swollen, it is impossible to decide whether we have to do with a simple hypertrophy and chronic induration or with incipient carcinomatous disease. The diagnosis can only be cleared up by amputa tion and microscopical examination. If one is satisfied to make an abso lute diagnosis from the study of the symptoms alone, as was done towards the middle of this century by Duparque, Lisfranc, Ashwell, Montgomery and others, why then of course we shall find that cancer of the uterus has in numerous instances been cured by amputation of the cervix.
Now, as we should so far as possible avoid undertaking this operation, by no means an insignificant one, without well-founded diagnostic reasons, we ought to welcome any criteria which would enable us to differentiate the commencement of carcinomatous disease from simple induration. Spiegelberg ' claims that the former is characterized, in the first place, by the density and immobility of the mucous membrane overlying the deep seated carcinomatous tissues, and further that the affected parts are not susceptible of dilatation by sponge-tenth or other similar agents, their natural elasticity having been destroyed by infiltration with cancer ele ments. Unfortunately the hopes born of Spiegelberg's statements are
justified neither by my own experience, nor, as it seems, by that of other physicians.
A correct diagnosis may undoubtedly be established by the use of these methods, when the mucous membrane slides freely on the underlying tissues, and a sponge-tent readily succeeds in dilating the cervical canal, but when these conditions do not obtain, we are not yet justified in making a diagnosis of cancer of the cervix uteri. The normal degree of mobility of the mucous membrane of the vaginal portion is so variable, and is so difficult of determination, that it would be improper to base a diagnosis of such far-reaching importance on so insecure, I am almost tempted to say so purely subjective, a foundation. And as regards the dilatability of the cervical canal by sponge tents or laminaria bougies, it seems to me that this also varies so exceedingly, leaving entirely out of consideration the fact that the different tents exhibit such varying powers of distension, that it has never aided me in reaching a decision in doubtful cases. Dense fibrous indurations often require a considerable time, and repeated intro duction of sponge tents, before they exhibit any noteworthy degree of dilatation, and, on the other hand, I have not seldom succeeded in dilat ing the os with surprising facility by the above means, in cases of well marked carcinomatous disease. Now while anatomical reasons would lead us to expect that tissues that have undergone cancerous degeneration, would, as a rule, soon lose their elasticity to a great extent, yet clinical observation teaches us that normal labor through an evenly dilated os, not very infrequently takes place in cases of advanced cancerous disease of the lower segment of the uterus; in other words, that cancer does not always entail a diminished dilatability of the cervix, or, at any rate, not to a degree that is always readily appreciable.
In those doubtful cases of the above description it is important to make a careful examination of the pelvic connective tissues surrounding the uterus. By so doing we are not infrequently able to detect at an early stage infiltration of these tissues, with more or less immobility of the uterus, and dense indurations, sufficient grounds for establishing a pre sumptive diagnosis of malignant disease of the vaginal portion.