Pyometra in Cancer of the Uterus.

DR. ANDRE LOMON, PARIS

"Pyometra is an accumulation or retention of a certain amount of pus in the uterine cavity. It occurs in a variety of uterine diseases, and is met with in cancer, in certain fibromas, in certain cases of stenosis of the cervix; in a word, whenever an obstacle is offered to the evacuation of infected uterine secretions."

Cancer of the uterus, especially cancer of the cervix, is by far the most frequent cause of pyometra. Thus of thirteen cases of pyometra cited by Bratoff, nine were due to cancer. And yet this complication of cancer of the uterus is not mentioned in the standard works on gynecology. For this reason I thought it interesting to report a case which I observed in the service of my teacher, Dr. Bazy, and to sketch the clinical and etiological facts in connection with this subject. The following is the history of the case:

Marie D., fifty-three years old, examined October 11, 1906. Admitted January 19; operated upon January 22, 1907; discharged cured.

The patient had been operated upon ten years ago for a colloid cyst of the ovary by LeDentu and had not menstruated since. She had been bleeding continuously for six months. For the past month she had hemorrhages which lasted one or two days. Her physician curetted the cervix and applied potassium chlorate. At present there is an abundant purulent discharge with a foul odor. The temperature chart shows irregular rises of fever.

The cervix is somewhat indurated, but not abnormally so, and is atrophied. Through the speculum three small red projections are visible in the cervix, which do not bleed.

Operation.—An incision was made from the pubes to the umbilicus, and revealed an adherent intestine in the neighborhood of the old scar. The intestine was not involved. The uterus was of a size corresponding to the third month of pregnancy, and was very soft. The left annexa had been removed, and in its neighborhood there were no adhesions, contrary to expectation. The two pedicles were tied, and both were found to be friable. The broad and round ligaments, even, were friable. The right tube showed a somewhat hypertrophied and inflamed fimbria. The large ligaments were cut at the level of the cervix, and is was noted that the cervix was adherent and very friable. The uterus was so soft that it could not be drawn up. It was punctured in order to empty it, and about 200 c.c. of a very foul grayish-green pus were removed. The uterus was then drawn up with forceps and was completely separated from the vagina, and removed. A drain was left in place and the abdominal wall sutured.

The uterus was opened in the median line, and its cavity was found to contain a little sanious pus. Its mucosa was wrinkled and rough, and in places there were vegetations with long pedicles. The body of the uterus was hypertrophied, but very soft, while the cervix was very hard and fibrous. A sound was introduced easily from without inward, but would not pass from within outward, which explained the retention of pus. On histological examination, made by Dr. Rubens-Duval, there was found a suppurative metritis, together with a cylindrical epithelioma at the beginning of the lower portion of the cervix, limited to this region and not yet extending to the pericervical adipose tissue.

Etiology.-The only statistics which have been published as to the frequency of pyometra in cancer of the uterus are those of Sinclair, who gives 6.2 percent in his article on cancer of the uterus in the work of Allbutt and Playfair. These statistics are based upon the tables by Burkle, which summarize operations by various German surgeons. In 273 cases of vaginal hysterectomy for cancer of the cervix there were 17 cases of pyometra. Lewers operated upon 67 cases of cancer of the uterus, of which 5 7 were cancers of the cervix. He found two examples of pyometra, or, in other words, 3.5 per cent. Lee saw five cases of pyometra but does not say in how many operations. Tait, in 31 vaginal hysterectomies for cancer, of which 28 were cancers of the cervix, found three cases of pyometra, or 10.7 per cent. In the hospital statistics of my teacher, M. Bazy, there were in one thousand operations upon women eight cancers of the uterine body and 28 cancers of the cervix, and among the latter one case of pyometra, i. e., 3.5 per cent.

All the authors who report cases of this sort agree that they usually occur at an advanced age. Most of the patients are over sixty, several over seventy, a few under sixty, and yet cancer is not more frequent at these ages. Statistics show that most cancers of the uterus are seen before fifty, and yet pyometra is not met with until after this age. All the patients had passed the menopause by several years; on the average from ten to fifteen and in some cases twenty-four years. There are several reasons why this should be so, the most important of which is the effect of senile sclerosis, which invades the neck of the uterus, but we believe that the menstrual flow, which once each month clears the cavity and tends to remove any obstacles that might form at the cervix, has a tendency to prevent retention of pus in the uterus. Pyometra develops slowly as the result of a progressive distention of the uterine wall.—La Tribune Medicale.

Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.