of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

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On the anterior wall, at the level of the internal os, is a thick-
walled sac opening into the cervix and large enough to hold a
goose egg. The walls of this sac are also soft and boggy. The
tumor which was shelled out of this sac during the operation is
4 inches long and 3 inches wide. On section it is seen to be
flesh-colored and a wavy irregularity of the cells is noted. It
is soft and apparently gangrenous in one small area.

. The ovaries contain a few follicular cysts. The tubes are
thickened and elongated. The microscope reveals a septic
metritis, a myoma undergoing degeneration, inflammatory
changes, and a purulent salpingitis.

Case III. — Mrs. M. L., aged twenty-seven years, was seen in
consultation with her physician. Dr. Rae S. Dorsett, the first
week in April, 1908, with a history of having had for several
years pain in the right side which was worse after exercise.
Last menstruation was in November, 1907. The abdomen was
considerably enlarged and extreme tenderness was noted on the
right side with a sulcus separating it from what was apparently
a five months pregnant uterus, pushed upward and to the left.
Diagnosis of fibroid complicating pregnancy was made, and
because of the relative position of the uterus and the growth
and the evidence of inflammatory changes present, operation
was advised. The patient was admitted to the Samaritan
Hospital on April 8, 1908, and supravaginal hysterectomy per-
formed on the ninth and specimen No. 3 removed. The patient
made an uninterrupted recovery and left the hospital on April 28.

Specimen No. 3 is a fibromyoma uteri with pregnancy.

Physical appearance. The fetus of five months is enclosed
in the unruptured membranes. The fibroma is intramural,
14 by 13 inches in circumference. Sections show the concentric



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krusen: fibroid tumors complicating pregnancy. 461

arrangement of fibres in a hard fibroma with softened areas
which can be easily scraped out. The whole specimen weighs
2900 G.

Microscopically, the main tumor mass presents the appearance
of a hard fibroma with here and there areas of very large spindle
cells with large round nuclei suggesting soft fibrous or sarco-
matous change. The blood-vessels have thick walls and are
numerous. The softened areas noted macroscopically are
chiefly necrotic tissue with small round-celled infiltration, espe-
cially surrounding the necrotic areas.



Fig. 2. — Fibromyoma uteri with pregnancy. Case III.

Diagnosis. — Fibromyoma (intramural) undergoing inflamma-
tory changes of the uterus with pregnancy.

Case IV. — I am indebted to Dr. Swithin Chandler for the
privilege of reporting this case. Mrs. M., aged twenty-eight
years, was admitted to the Garretson Hospital on April 15, 1908.
Her health had previously been good until six weeks prior to her
admission to the hospital, when she consulted Dr. Chandler who
made the diagnosis of fibroid tumor complicating pregnancy and
advised hysterectomy, which was performed on April 16. The
ovaries were healthy and were not removed. The patient made
an uninterrupted recovery and left the hospital on May 5, 1908.



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462 krusen: fibroid tumors complicating pregnancy.

Specimen No. 4 is a uterus with fibromyoma and pregnancy.
A fibromyoma of typical appearance on section is seen to occupy
the interior wall and fundus of the uterus. A fetus of about six
weeks of age occupies the uterine cavity. The membranes are
intact. The whole specimen weighs 850 G. and is 12 inches
and 14 inches in circumference. The tumor is hard and on
section reveals the distinct concentric arrangement of fibers
characteristic of fibroma. The color is gray. Microscopically,
it is composed of elongated connective tissue cells and an inter-
cellular substance of fibrous material traversed by thick-walled
blood-vessels.

Diagnosis. — Intramural fibromyoma of the uterus with preg-
nancy.

Case V. — Mrs. E., aged thirty-four years, the wife of a physi-
cian, was admitted to Samaritan Hospital on June 14, 1906, with
a history of having had a miscarriage a few weeks previously.
On examination, a fibroid tumor of the uterus was found extend-
ing above the umbilicus. The patient was running a septic
temperature and I declined to operate until June 28, when it
became very apparent that the only hope of saving the patient
was by celiotomy, which was performed on that date. The
superior surface of the fibroid was found adherent to the lower
border of the stomach and the omentum. This part was so
much infected and so rotten that it became detached during the
removal of the growth, and the detached portion of the tumor
with the omentum was subsequently removed. The patient
made a slow recovery and left the hospital on August i, 1906,
forty-nine days after admission.

Pathological Record. — The uterus was enlarged uniformly.
Weight, 5 pounds. Opened interiorly, it revealed a single tumor
attached to the fundus by a broad base. The tumor resembles
muscular tissue. The interior of the uterus was filled with pus
which, staified, shows streptococci. Fundus of the uterus was
attached to the omentum and suppurating. The tumor was
composed of smooth muscle fibers, but very little fibrous tissue.
The endometrium was slightly thickened and showed inflamma-
tory changes.

Diagnosis. — Myoma of the uterus.

COMMENTS.

Frequency. — According to Jewett, fibroids complicating preg-
nancy are not common. Pinard observed eighty-four instances
of this complication in 13,915 consecutive cases of labor, or 0.6 per
cent., and forty-nine of these patients were over thirty years of
age when pregnancy first occurred. Parvin stated that relative
sterility usually resulted from fibroids of the uterus; thus, while
the average sterility of women is one in eight, in those having
fibroids it is one in three. Charpentier's statistics of 1,554 cases



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krusen: fibroid tumors complicating pregnancy. 463

of fibroids showed sterility in 476. Conception does not usually
occur if the neoplasm is submucous or interstitial, but it is more
apt to be found in the subserous type. The changes in the
endometrium frequently cause premature expulsion of the ovum.
The profuse and irregular hemorrhage and excessive glandular
secretions present unfavorable conditions either for the fecunda-
tion of the ovum or for its development should fecundation occur.
It has been frequently noted that the removal of a polyp from
a sterile woman is very shortly followed by conception, although
many years of sterility have preceded.

Another cause of relative sterility is the great difficulty of uter-
ine dilatation induced by the growth. In one interesting case re-
ported by Haultain, the dilatation of the uterus was so interfered
with that the cavity was distended in the form of an hour-glass
with the placenta situated in the upper compartment and the
fetus in the lower until the eighteenth week, when, after the fetus
was expelled, it was found impossible to remove the placenta as
the communication between the two cavities was not large
enough to admit a finger, and death occurred from septicemia.

Dangers. — It may be well to enumerate the dangers and degen-
erative processes that may be produced by this complication of
pregnancy :

1. These growths usually increase in size during this period;
this is often edema rather than true hypertrophy.

2. In pedunculated growths the pedicles may become twisted
and the growth gangrenous, as in Case II, and peritonitis ensue.

3. The tumor may affect the position of the child. In 01s-
hausen's series 53 per cent, were vertex, 24 per cent, breech,
and 19 per cent, transverse in position. Lefour found that in
100 pregnancies 49 per cent, showed abnormality in presentation.

4. The presence of the tumor may produce placenta previa
with all of its dangers to both fetal and maternal life.

5. It may cause postpartum hemorrhage of a serious type by
interfering with normal uterine contraction.

6. Preexisting adhesions in a fibroid pregnant uterus may
produce symptoms similar to those found in adherent retro-
flexed gravid uterus, and impaction of the mass in the pelvic
cavity and abortion.

7. A fibroid pressing upon the tubes has been noted as a
cause of tubal pregnancy, the condition being unrecognized until
rupture occurred.

8. The most common result of this complication, but not the



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464 krusen: fibroid tumors complicating pregnancy.

least dangerous, is abortion, and as normal involution is seri-
ously impeded, both hemorrhage and septicemia are liable to
occur; for instance, Lefour found that in 307 cases abortion took
place thirty-nine times, ending fatally to the mother in fourteen
cases. Nauss, in 241 cases, noted forty-seven abortions, and
Lefour, even in twenty-three induced abortions, observed three
deaths; so that even when the complication was recognized and
a selected procedure employed danger was present.

9. A tendency to prolapsus of the umbilical cord has been
noted.

10. Rarely a spontaneous thinning and rupture of the uterus
may occur.

11. Webster claims that there is greater degeneration of the
cardiac muscle and of the renal and hepatic epithelium and that
the heart is more dilated than in normal pregnancy.

12. The pressure symptoms are often annoying; varicose
veins and edema of the lower extremities are frequent as venous
engorgement results from obstruction of the veins while the
arteries continue to pour blood into the neoplasm.

It is by a careful study of these dangers and possibilities in
the given case that we can arrive at a decision whether to operate
or to wait for delivery.

Diagnosis. — ^The diagnosis of a fibroid tumor complicating
pregnancy is often beset with difficulties. It may be mistaken
for multiple pregnancy or gestation in a bicornate uterus. In
Case III, which presented a distinct sulcus between the two
enlarged areas, this fact was borne in mind. The sudden increase
in size of a neoplasm should direct attention to the possibility
of pregnancy. The presence of amenorrhea coincidently with
enlargement of the uterus is almost characteristic. When
menstruation continues in spite of gestation, as it occasionally
does, then palpation is the only method of making the diagnosis;
and the value of an anesthetic in order to make a satisfactory
bimanual examination may be emphasized.

If the patient gives, as in one case, the history of gradual
abdominal enlargement extending over several months and the^
a cessation of menstruation, diagnosis is less difficult. But
where there is simultaneous development of the uterus with
amenorrhea, the physician is aften perplexed and compelled
to study the case carefully before giving a definite opinion.

Treatment. — The treatment must be decided only after the
study of the individual case, taking into consideration the size,



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krusen: fibroid tumors complicating pregnancy. 465

condition, and position of the neoplasm, and the period of ges-
tation. Enucleation of the growth during pregnancy is a formid-
able procedure on account of the vascularity present and be-
cause of the danger of sepsis, hemorrhage and subsequent rup-
ture. I believe it unwise to perform myomectomy upon the
pregnant uterus.

Abortion or the induction of premature labor is unjustifiable
because of the dangers encountered. If the patient is seen after
the fetus is viable, the case should be carefully watched and
Cesarean section, followed by supravaginal hysterectomy,
performed about the middle of the eighth month. Noble states
that in necrotic and infected fibroids complicating labor or the
puerperium and when virulent infection exists, the old method
of extraperitoneal treatment of the pedicle by means of the
serre-noeud or the elastic ligature and transfixion may be
indicated.

In Case II in which we had a necrotic fibroid and perimetritic
abscess we employed the gauze coffer-dam drain.

Davis warns against the attempt to perform celio-hyster-
otomy in these cases, as the uterus which is the seat of fibroid
disease will not heal properly after incision and suture.

Even in those cases in which labor occurs spontaneously,
certain complications have been noted. The growths hinder
uterine contraction or may cause exhausting after-pains. Great
difficulty may be encountered in removing the placenta^ many
years ago Goodell called attention to the danger of attempting
to force the hand into the fibroid uterus. The danger of sepsis
is greater. Spiegelberg believes this may occur in subserous
growths due to the passage of microorganisms through the
lymph spaces.

During the process of labor the pains may be very irregular,
often insufficient; or sometimes a tetanic condition supervenes.
Neither the maternal nor infantile statistics give much encourage-
ment toward allowing nature to take her course in these cases.

Susserott found in 147 cases a maternal mortality of 50 per cent,
and infantile mortality of 66 per cent. Nauss found a maternal
mortality of 54 per cent, in 225 cases, and infantile mortality
of 57 per cent, in 117 cases, and in Lefour's statistics of 300
cases the mortality of delivery by natural passage was 25 to 35
per cent, for mother and 'jj per cent, for the child. Pinard,
however, presents a more favorable series of fifty-four cases in
which labor was spontaneous with mortality of 3 . 6 per cent.
6



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466 BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS.

As said before, each individual case must be studied and the
conscientious physician thus determine whether the interests
of both mother and child are best conserved by a radical or a
conservative policy. From my own experience I feel convinced
that supravaginal hysterectomy is the operation of choice in
those cases in which the growth is of sufficient size to interfere
with labor or shows evidence of degenerative changed.

127 North Twentieth Street.



PRIMARY ADENOCARCINOMA OF THE BODY OF THE
UTERUS, WITH SPECIAL REFERENCE TO AN
EARLY DIAGNOSIS.

BY

CHARLES NELSON BALLARD, M. D.,

Lately Associate Professor of Gynecology andClinical Gynecoloarjr at College of Physicians

and Surgeons (Medical Department of the University of Illinois) ; Surgeon to Marion

Sims' Sanitarium, Chicago; Attending Surgeon at West Side Hospital,

Chicago; Attendant in Gjmecology at the West Side Free Dispensary.

Oklahoma City, Oklahoma.

(With four illustrations.)

In writing this paper it is very vividly brought to my mind
that at a recent date I reported a study of the same subject.
This subject, however, has been an impressive one to me and
I have been compelled by sheer necessity to make a special
study of it. These cases have come to me so frequently with
an incorrect diagnosis that I have been impressed with the need
of further investigation to discover some means to secure an
earlier recognition of the condition, so that many lives may
be saved that now are sacrificed.

This should be of especial interest to the medical inan in gen-
eral practice, for it is for him to make an early diagnosis. It is a
fact that usually these cases come to the physician late in the
progress of the disease, yet how many times do they come,
saying that they are flowing too much or that they have a pro-
fuse leucorrhea, and we advise them to take a vaginal douche
for the leucorrhea, or to keep quiet for the bleeding, or prescribe
some hematic remedy, and tell them that they will soon be better.

If the patient is at the age of the menopause, we tell her that
is what she might expect at that age, and do nothing for her,
only ask her to be quiet at such times, and that after the change
she jwill be all right. This is gross carelessness. We should
at least make a vaginal examination and exclude that condition
so prone to produce malignancy — ^lacerated cervix. If the cer-
vix is not lacerated, is it eroded; if neither condition exists, then



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BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS. 467

is there tubal or ovarian trouble? Examine into the consistency
of the organ; is it soft or hard, irregular or smooth, is it normal
in depth and position; is it movable in all directions; is it tender
to pressure, is pain elicited on motion?

After all these means are exhausted, and nothing is found, do
not be satisfied; if the hemorrhage continues to be frequent and.
profuse, go further, and do a thorough curettage and examine
thoroughly all scrapings microscopically.

After doing all this, if the hemorrhage still persists, we are
warranted in advising a hysterectomy. Even after this is done,
we may not be able to discover any lesion macroscopically, but by
examining carefully every part of the uterus microscopically,
we will finally discover that there exists an area of malignancy.
If we had neglected this condition until it could have been diag-
nosed macroscopically our patient would have been past help,
and another life lost that might have been saved by careful
investigation, which it is our duty, as physicians, to make.

Many times I have been scored by colleagues for what they
term radical procedures in doing a hysterectomy, when the
apparent symptoms to them did not warrant it.

Investigation in this particular line has been so gratifying to
me that I am willing to be scored for what I can very properly
term conservative life-saving work, when I can and have so
frequently demonstrated that my diagnosis was correct, and
that my conscience was clear, knowing that I had saved a life
that must have been lost in the hands of the so-styled conser-
vative (f) surgeon.

Should we remove a uterus at the age of fifty years, aijd after
a thorough investigation find that no malignancy existed, what
serious harm has been done? It has served its time of useful-
ness; it is not normal, or it would not present abnormal symp-
toms, such as would bring the patient to us asking our advice.
Then why not remove it, and stand on safe ground, rather than
wait till we are absolutely sure of the gravity of the case, when,
oftentimes, it would be too late to operate? How much better
to err on the side of safety to our patient than to neglect a case
suffering with the most dreaded of all diseases.

You may say, why not do a curettage for diagnostic purposes?
Because, not finding malignant cells in the scrapings would
not be proof that malignancy did not exist, as can be seen by
some of the cases reported. Yet it is our duty to do a curettage
in these cases, for, if thoroughly done, it may reveal the source of



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468 BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS.

the symptoms. Specimens taken from one of my cases reported
herein were diagnosed as four or five different pathological condi-
tions, by as many expert pathologists. How this could occur
can be understood, when we know that this disease advances by
stages, and that each stage shows a different appearance; differ-
ent fields m^y contain squamous cells, columnar cells, giant
cells, lymphoid cells, .or much degenerated interstitial tissue, so
any of these conditions might lead to a diagnosis, and the most
important one — ^malignancy — ^be overlooked.

According to Billroth, we may class all the tumors of the
uterus which are of a typical epithelial formation as '* carcinoma
epithelial, and carcinoma glandular.*' Virchow says that "in
organs which are disposed to secondary growths, primary growths
are rare.'* How seldom secondary growths involve the uterus,
even when the primary growth of other organs is widely ex-
tended !

The growth of cancerous tumors is at the expense of the sur-
rounding tissues. They have a double food supply, they ab-
sorb the nutritious element elaborated for the healthy normal
tissues and they destroy in some unknown way the tissues them-
selves for their own maintenance. Benign tumors are simply
new formations displacing adjacent normal tissues.

When we speak of cancer we must not always expect it to
appear the same, either macroscopically or microscopically.
Every organ seems to have its own peculiar form of cancer,
and the uterus is no exception to the rule.

In many examinations of varied specimens of carcinoma of the
body of the uterus, we find it developing progressively through
stages, beginning with adenoma and passing through bizarre
forms of evolution of the uterine glands, into ordinary spheroidal
celled carcinoma. These changes may take place in rapid succes-
sion, or one stage may persist for some time, and then from some
irritation, mechanical, chemical, or otherwise, progress rapidly
to the completion of atypical malignant cells. We may ob-
serve the growth at any changing point and hence see many
forms and characters of cells. Usually the most advanced
stages can be seen in the oldest and deepest part of the growth,
while in the growing portion the earlier stages are seen.

It is not at all an easy matter to distinguish the tissues under-
going the change into malignancy. Hence we advise much
study to be given any specimen, and many specimens taken
from the portion of the tissue to be studied. It requires much



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BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS. 469

time to make an accurate and safe diagnosis in these cases.
Hurried and careless examinations are fruitful of serious error.

A marked increase in the gland-like spaces is an important
feature in malignant adenoma and adenocarcinoma. We can-
not consider this as a point of positive diagnosis, however, for it
often occurs in endometritis. Yet in the latter condition the
superficial portion of the mucous membrane contains but few
glands, hence a marked increase in this region would be con-
sidered as suspicious. A marked subdivision of the glands
points towaM malignancy, while in endometritis the division is
limited. In typical malignant adenoma the glands are so
close together as to be separated only by a single row of connect-
ive-tissue cells. In malignancy the glands run in various
directions, while in simple endometritis they run vertical to the
surface. They are so increased in malignant growths that they
form a complex network, in which it is impossible oftentimes to
distinguish them, while in endometritis they can be distinctly
outlined.

Cancer in the body of the uterus must arise from the gland or
from the surface epithelium. When it begins from the surface
epithelium, the layers increase, crowding of cells takes place,
until we have a change in the shape of the normal columnar
epithelial cell into an atypical squamous cell. These cells some-
times become dry and scaly. This condition is known as ichthyo-
sis uteri. Groups of cells in the older portions of the growth
undergo a hyaline change; the nuclei become changed, they
become swollen, stain less deeply and more diffusely than usual,
and break up into fragments and granules. These cells arrange
themselves into nests, presenting the appearance of the pearls so
characteristic in typical squamous epithelioma. All the inter-
vening stages can be followed sometimes from adenocarcinoma
to the imitation of the pavement-celled epithelioma. Cancer
in the body of the uterus cannot be recognized as early as that
of the cervix or the vagina, but by close observation of the symp-
toms it can be sufficiently early detected to promise a very
favorable prognosis. The progress here is not so rapid as in
the cervix, hence much more amenable to treatment. This*
disease is not confined to parous women, for many times virgins
are found afflicted.

Being a newgrowth, the parts are more or less thickened.
The breaking-down process, commencing sooner or later, affects
all tissues. The ulceration in carcinoma has no anatomical



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470 BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS.

boundary nor any defined limits. As an example of the difference
between healthy granulation tissue and that of beginning car-
cinoma, we refer you to these conditions of the cervix. There
the granulations of an ordinary erosion are separated from one
another by sulci, uniform in disposition, and never presenting
any appearance suggestive of sloughing, but when the cancerous
growth is beginning to break down it looks as if it had been
scratched, perforated, or worm-eaten.

Herman says, in the British Medical Journal of 1894, that the
microscope, as usually used, is not a safe instrument for diagnosis
in these obscure cancers in the body of the uterus, for a small
portion taken from some part of the organ and examined is most
likely to be productive of an incorrect diagnosis. For an accurate



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 47 of 109)