PRIMARY CANCER OF THE VAGINA.

BY C. HENRI LEONARD, M. D., PROFESSOR OF MEDICAL AND SURGICAL DISEASES OF WOMEN, MICHIGAN COLLEGE OF MEDICINE, DETROIT.

The primary seat of a cancerous growth in the vaginal wall is of rare occurrence. Indeed, many extensive writers upon gynæcology deem it an improbable occurrence. But when one positively sees a case of cancer that actually had its origin in the vaginal wall, and extended itself, as a secondary deposit, to the uterus, a more than passing notice should be given it. This the writer has witnessed in the person of a young, unmarried lady, aged 22 years. Besides the youth of the patient, the case is also interesting from the extreme toleration of morphia and opium.

To give a brief history of the case: At the time I saw the lady she was in apparent good flesh, and, save the excessive pain that she suffered, seemed not to be needing medical advice or treatment, although for relief from this pain she had received professional services from several medical gentlemen. Among this number had been a homopathic practitioner, who had discovered a small anal fissure and had drawn a rubber band through it. This was suffered to eat its way out, for the space of a week or so, when a change was made in the medical attendant. The physician that was newly called removed the band that had been inserted by the former attendant, as it only served to increase the patient's sufferings, since the fistula was regarded as of trivial matter. Pain all this time was intense in the small of the back, and it radiated down the sides and legs. Morphine was given to relieve this with the hypodermic syringe. Large doses were required, and they only furnished temporary relief. A short time after this I was called in consultation, as cancer

was feared to be present by the physician then in attendance, although the age and general appearance of the patient was very much against any such diagnosis. The patient's mother, by the way, had died of cancer of the womb.

On digital examination I found a large, circumscribed, cauliflower mass springing from the posterior vaginal wall. Its lowest point came down to within one and one-half inches of the vulva; it extended up to, but did not involve the posterior culde-sac. This I was careful to verify by both digital and ocular -per speculum-examination. The mass also extended nearly two-thirds of the way about the circumference of the vagina, being widest at the middle of the mass.

The mass was made up of leaflets, so to speak, of friable and easily bleeding tissue. The index finger could be passed to the depth of its first joint between these friable proliferations. The tumor was also excessively tender to the touch.

A portion was clipped off and subjected to microscopical examination by myself, and found to be a well marked case of proliferating epithelioma, and, judging from its brief clinical history, of very rapid growth.

The prognosis was a grave one, and surgical removal advised. This the patient refused to submit to unless I could promise her there was little or no chance for the unwelcome visitor's return. This I could not promise, as the pelvic glands were thought to be involved, there being some cellular hardness, and so much and such excessive pelvic pain. The rectum, I might add, was not involved as yet.

Morphine, belladonna, etc., were ordered for the control of the steady and excruciating pain that she was suffering, but they had little or no permanent effect; indeed, sleep could only be obtained after the administration of chloroform by inhalation, and then only for a short period of time.

Two weeks from the first visit I saw the patient the second time, so as to still further give me a chance of verifying my diagnosis given at the first visit, as it had been criticised by several that had seen the case before my first visit. The regular physician in attendance, however, agreed fully with me on my first diagnosis.

The tumor, at its widest portion, had now completely extended itself around the vagina, and had involved the vaginal portion

of the urethra, with a slight involvement of the mucous portion of the same; this gave rise to severe pain upon urinating, and induced more or less bladder tenesmus. The leaflets or epitheliomatous proliferations measured now some two and one-half inches in length, and hung pendulous in the vagina from the left lateral wall. These larger leaflets measured over one-half an inch in depth. On other portions of the cancerous mass the proliferations were thicker and less prominent, although all broke down easily and bled profusely on the gentlest manipulation. There was more infiltration of the pelvic tissues than was observed at the first visit, also a slight involvement of the vaginal portion of the cervix uteri, though no positive enlargement of the pelvic glands could be made out, as it was impossible, from the hardness of the tissues, of making a careful examination of them. Both examinations were made under chloroform. The patient was now rapidly becoming emaciated from the constant drain upon her system through the intense pain that she always suffered, and from the exhausting discharges that were also always present. One would scarcely have believed that two weeks could have made such a change in one's appearance. She was now taking fourteen grains of morphine daily by mouth and rectum, and a part by the hypodermic syringe; with all this, she frequently had to have chloroform administered by inhalation before rest, for even an hour or so, could be secured to her.

From this date onwards matters progressed from what was now severely bad to even a much worse condition, till death at last, in the space of a few weeks more, put an end to her sufferings. Exhausting hemorrhages, from the sloughing of the proliferating cancerous mass, aided her dissolution very materi ally.

Klob, in his "Pathological Anatomy of the Female Sexual Organs," incidentally speaks of the primary infiltration of the vagina with cancerous tissue in this way:

"Cancer of the uterus has been known to occur secondarily as a similar affection of the ovaries, and, in very rare instances, to a continuance of primary carcinoma of the vagina and peritonæum.'

From the severity of the symptom of pain, I am inclined to the view that my patient also suffered from some peritoneal involvement quite early in the history of her disease.

J. Matthews Duncan, in his lectures, mentions "five cases which have been entered as cancer of the vagina" in the "Martha "wards. He says nothing further concerning them, though speaks at a considerable length concerning cancer of the womb.

Athill, in his "Clinical Lectures on Diseases of Women," says:

"Epithelial cancer occasionally attacks the vagina as a priary disease. We have had two examples of this recently in the hospitals. In one, the superficial ulceration extended to the very vulva, and the patient sank, worn out with pain and repeated, though trifling, hemorrhages. In her case the entire surface of the vagina was constantly covered with a dark, pultaceous mass. The other case was admitted for a profuse hemorrhage that threatened life. This was found to proceed from a spot on the anterior wall of the vagina not larger than a split pea; it was hard to the touch, and had a puckered appear

ance.

Barnes, in his work upon "The Diseases of Women," says: "Primary cancer of the vagina is exceedingly rare. McClintock says no well marked and undoubted instance has fallen under his notice. All cases of vaginal cancer he found had spread from the uterus or vulva. Dr. West believes that the rarity of primitive vaginal cancer has been exaggerated. I cannot absolutely contest McClintock's statement, but I have now and then met with a peculiar contraction of the vagina in old women, attended with ulceration and offensive discharges, which I believed to be of cancerous nature, and in which I concluded that the uterus was not involved."

This explanation of Mr. Barnes is really an admission that he has not himself seen an undoubted case of primary cancer of the vagina. He quotes from Dr. Cayley, however, "a case of epithelioma propagated by contact from the posterior to the anterior wall of the vagina," and concludes that cancer frequently springs up in an adjacent part by contact, when it is opposed to the primary seat of the disease. This was quite marked in the case I have just reported, otherwise I could hardly explain the speedy involvement of the whole circumference of the vagina between my first and second visits, made only two weeks apart.

The above are the only references that I can find upon the vagina as the primary seat of cancerous trouble, among our authorities. If Barnes has never seen a case, and neither

Thomas, Emmet, Byford, Goodell, Sims, Chapman, Simpson, Tilt, make mention of the trouble, save as it appears secondary to uterine or vulvar involvement, then this case of mine is worthy of record from its rarity alone, although the therapeutics in the case show nothing peculiar, except the tolerance of large doses of morphine. The youth of the patient may also be regarded as another exception to the usual development rules that seem to govern the appearance of cancerous disease.