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diagnosis, sections must be taken from every part of the organ
for examination. It is well in discussing the diagnosis of carci-
noma of the uterus to consider the anatomy of the growth, for it
is only in this way that we can distinguish carcinoma from the
other malignant growths of the uterus.

Waldeyer says that carcinoma of the uterine body always
originates in the preexisting pure epithelium. The epithelial
newgrowths in which are found the glandular tubes with a
lumen are distinguished as adenoma, while by carcinoma we
mean those epithelial newgrowths whose characteristics in form,
size, and grouping deviate entirely from the normal epithelium,
so that carcinoma is to be understood as an atypical epithelial
neoplastic growth.

The cause of carcinoma is, so far, unknown. It might be of
interest, however, to note some supposed predisposing conditions.
Statistics lead us to believe that any condition that lowers the
vitality of the endometrium is a predisposing cause. As an
example, the presence of a fibroid tumor in the wall of the uterus.

Pequand says that usually there are about six times as many
cases of carcinoma of the cervix as of the body of the uterus, but
when there is present in the body of the organ a fibroid, then
the cases are about equal; hence from this we would conclude
that the presence of a fibroid in the body of the uterus would be
a predisposing cause.

A fibroid in this position keeps up a constant and prolonged
irritation, interferes with the circulation, causing a high degree of
congestion, achronic glandular endometritis, followed by adenoma;
and, in turn, this may be followed by adenocarcinoma, by regular
and then irregular proliferation.



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BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS. 471

The traumatic theory is given much weight by many clinicians.
A single traumatism is probably of little consequence, but an
injury that continues to keep up an irritation, such as laceration
of the cervix, or the irritation from pipe-smoking where we so
often find epithelioma of the lip, or the carcinoma of the scrotum
and limbs of chimney-sweeps and paraffin workers, would seem
to show that the effect of chronic irritation may be important.

Through the courtesy of Dr. Arthur S. Jackson, of Reno,
Nevada, the attending physician, I am able to report a case
that demonstrates most clearly the necessity for careful and
conscientious investigation.

Mrs. R., age fifty-one, married thirty-four years, occupation,
housewife. She has given birth to five children and has had
five miscarriages. The last miscarriage was at the age of thirty-
six and was caused by a fall, when gestation was between two
and three months. Since this time she has given birth to two
children at full term, one of which was an instrumental delivery.
During the last gestation, which occurred at the age of forty-
three, the patient complained of considerable pain in the left
side, which continued at intervals after confinement. These
attacks of pain came on more frequently and more severe until
the time of operation.

She reports that menstruation was more profuse about five
years ago. She suspected menopause at this time, but the flow
returned to a normal condition, and remained so until May, 1907.
After this latter date it was quite irregular until June 15, 1908,
when a profuse hemorrhage occurred with severe pains in the
uterus and the left ovary. In March, 1907, the patient was
attacked with severe pains (rheumatic in character) in the
lower limbs and shoulders, accompanied by swelling of the joints
and considerable impairment of motion. Melancholia developed
to a marked degree, with causeless crying and dread of impending
helplessness. She lost twenty-four pounds in weight during
the last year. A profuse vaginal discharge has been constant,
dark in color, and had a very disagreeable odor. This patient
had consulted several well-known physicians, all of whom gave
her some remedy for her rheumatism, passing her complaint of
profuse leucorrhea and repeated hemorrhages practically un-
noticed. They did not even make a vaginal examination, simply
considering it a case of you-will-get-well-after-menopause, and
allowed her to go at that.

She failed to get relief from the treatment given her, and hence,
as is usually the case, she continued to go from one doctor to
another, till she did find one who made a more careful examina-
tion and discovered the source of the trouble. He continued
the examination externally and per vagina and rectum until he
discovered enough pathology in the pelvis to produce all the



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472 BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS.

symptoms complained of, and to lead to more grave conditions
if not attended to in due time.

The findings were as follows: in addition to the rheumatic
pains, tenderness was found in the left iliac fossa; the left ovary
was enlarged and tender; the cervix was lacerated, enlarged, and
hard; the body of the uterus was slightly enlarged and its mo-
tion somewhat limited; in consistency it was practically normal
and the surface was smooth. The urinary examination showed
nothing of special value. The gravest pathology was considered
to be in the body of the uterus, and in view of the age of the
patient, her history and symptoms presented, it was thought
most likely malignancy, and removal of the organ was advised.

I was called in consultation, confirmed the diagnosis and
earnestly advised the treatment suggested. She entered the hos-
pital July 15, and two days later we did an abdominal hysterec-
tomy (my operation of selection in cancer of the uterus). Under
inspection the ovaries were found to be enlarged and cystic.
They were adherent, being the cause of a slight fixation of the
uterus. The uterus was more closely examined, and was found
to be a little larger than normal and harder in consistency. The
blood-vessels in the broad ligaments were in a varicose condi-
tion, which I find is rather common in these cases. The patient
stood the operation well and made a very satisfactory recovery,
leaving the hospital in two weeks. At the time of leaving the
hospital she had regained her lost motion almost entirely, and is
more free from pain than she had been for fifteen months.

She is now, three months after the operation, free from rheu-
matic pains and has complete motion. She is gaining in weight
and strength and says that she is in every way a new woman.
Immediately after the operation was completed the uterus was
incised and a macroscopical examination made. No special
pathological condition was to be seen. The gross specimen was
given to a local pathologist with instructions to make sections
and drawings to show the condition of the endometrium, if it
existed there, that would produce the symptoms found at the
original examinations. The case was reported by Dr. Jackson
at a meeting of the Washoe County Medical Society, and in
addition to his report the pathologist was asked to give his
microscopical findings and show by his drawings what he had
found. He demonstrated some glands from the cervix and body
of the uterus whose orifices were patulous and whose lumen
contained many blood-corpuscles. The intervening tissue was
undergoing degeneration. The walls of some blood-vessels were
thickened while the lumina of others were entirely obliterated.
His conclusion was that the organ was undergoing degeneration,
not at all uncommon at this time of life, and that the symptoms
were those frequently found at this age. His investigation was
concluded with this amount of superficial examination and the
case reported as one of not uncommon occurrence. I was not
satisfied to allow the case to go without a more thorough search-



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BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS. 473

ing for the cause of the symptoms. I was able to interest in this
investigation Dr. A. W. H. Wullschlager, of Reno, Nevada,
surgeon U. S. Army and pathologist, and Professor Fransden,
pathologist at the Nevada State University, and it is to these
two experts that I am indebted for the following pathology:

The dimensions of the uterus were 7.5 by 4.5 by 3.5 centi-
meters. The left oyary was enlarged, cystic, adherent, and
slightly prolapsed. The veins in the broad ligaments were ex-
tensively varicosed. No abnormal condition could be noticed
in the endometrium. The cervix was lacerated and erosions were
abundant on the everted surfaces. The uterine wall was
thicker than normal. Microscopical description. The uterus
was cut into many small pifeces, distributed over the body,
fundus, and cervix. For convenience Qf description we will



Fig. I. — Showing early invasion of glands of fundus.

divide it into: i. Mucosa. 2. Glands. 3. Muscle and connect-
ive tissue. 4. Blood-vessels. 5. Malignant area.

Mucosa. — The microscopical findings showed that the mucosa
in the regions extending from the median line of the fundus to a
little below the right ostium tubse, was in many places devoid of
epithelium. As we neared the. cervix the epithelium became
« more normal, being but little disturbed one centimeter above the
internal os. The mucosa of the cervix was practically normal
except in a few spots where there was much crowding and some
displacement of cells.

Glands. — ^The uterine glands were crowded so closely together
in some regions as to displace almost entirely the connective
tissue which should separate them. In many places the epithe-
lial cells lining the glands were so crowded that they were pushed
out of place, becoming stratified and occupying the lumen of the
gland. In other places the basement membrane was broken
down and the cells were found nesting in the position normally
occupied by connective tissue. This latter process had taken



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474 BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS.



Fig. 2. — Early adenocarcinoma of fundus



Fig. 3. — Very early disturbance of the columnar epithelium of the
cervix (secondary invasion).



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BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS. 475

place so extensively in certain regions of the fundus that the
interstitial tissue has been wholly destroyed and its place occu-
pied by many-layered, irregularly-shaped epithelial cells. These
were atypical squamous epithelial cells, formed by the process
of metaplasia.

Figs. 1,2,3, show different stages of this process.

Muscles and Connective Tissue. — ^The muscular tissue, in
places, was replaced by a superabundunce of connective tissue.
In other regions the fibers of both tissues were broken and ir-
regular. In these spots the connective tissue contained but few
nuclei and was undergoing degeneration.

Blood-vessels. — The blood-vessel walls were thickened and
many had occluded lumina. This was especially marked as we
came near the malignant area.



Fig. 4. — Invasion of connective tissue by malignant cells, more advanced
than Figs, i and 2.

Malignant Area. — The carcinomatous area was limited, prac-
tically, to the fundus, while in many sections taken from the
cervix, an occasional view could be had of cells of whose m.alig-
nancy there could be no doubt. The changes in the cervix were
not so advanced as in the fundus, showing plainly that the disease
was primarily that of the fundus, with secondary invasion of the
cervix. In the fundus nesting of the cells was observed. In
some masses the cells contained long nuclei; while others were
made up of cells with a large amount of protoplasm and round
nuclei. These were squamous cells. Karyokinetic changes
were to be seen as well as nuclear clumping. Cells with granular
nuclei were plentiful. But few giant cells were noticed. No



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476 BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS.

pearls were found. Squamous cells, columnar cells, and cells
containing the comma nuclei, all found in this specimen, would
represent some of the changes which take place in the process of
metaplasia in the uterine mucosa.

It has been taught by most pathologists, until the last few
years, that all cancerous growths of the uterus primarily existed
in the cervix, but recent investigation has changed the teaching
very materially. It is now known that many cases occur as
primary carcinoma of the body of the uterus, and that the cervix
may remain free throughout the process of the disease, for it
extends most rapidly in the lateral direction.

A second case which I have already reported in another article,
I wish to report again here, as it is of interest in this connection.
A more detailed account of this case can be obtained by referring
to the October number of Surgery, Gynecology, and Obstetrics,

Mrs. M., aged seventy years, occupation housework, married
fifty years; she has given birth to four children, all of whom are
living and well. The births were all norMial and convalescence
uneventful. There were no miscarriages. Her father died at
the age of seventy-nine, with rheumatism; her mother died at the
age of seventy, cause of death unknown, but it was not cancer in
any form. Patient has one brother who is living and well, and
three sisters, one of whom died at the age of eighty-six, with
pneumonia — the others are alive and well.

Patient began to menstruate at the age of fifteen, was always
regular and normal. ^ Menopause occurred at the age of forty-
five, since which time she has never had leucorrhea nor any
bloody discharge. She has been free from anemia and cachexia.
The organs of nutrition and circulation are normal. Nothing
in her family history indicates a hereditary tendency to any
disease. In 1901 the patient fell from a street car, alighting in a
lateral sitting position, fracturing the neck of the femur. The
accident confined her to the house for two years. She was able to
walk about with crutch and cane. After she had suflliciently
recovered to be about her apartments again, she noticed a differ-
ent feeling in the pelvic region, a sense of weight. This symptom
was slight at first, but grew more severe. She noticed that the
recumbent position gave her relief, but no examination was made
until the present illness occurred.

In March, 1906, 1 was called to see her and I found that she had
had a profuse hemorrhage following a little extra exertion in
attempting to lift a piece of furniture. I made a careful exami-
nation and found the cervix and body of the uterus normal in
position, size, and consistency, with a normal appearance at
the external os. The organ was movable and showed no pain
nor tenderness during the examination. The only abnormality
noticed was a slight fullness, especially marked on the left side.



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BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS. 477

Proper precautions were taken as regards the hemorrhage
which ceased in a few days and the patient recovered sufficiently
to be about her apartments again. But after another little
exertion, a second hemorrhage occurred, and a third one within
three weeks, the last one being more profuse than the preceding
ones. I influenced her to go to the hospital for a curettage for
diagnostic purposes. After the usual time for preparation she
was taken to the operating-room and anesthetized. A thorough
examination was made, and at first I found no more pathology
than has been stated above, except possibly a boggy feeling to
the side of the uterus. The careful use of the sound showed
that the uterus was normal in depth and position. After dilating
the cervix, a dull curette was carefully introduced and slowly
moved about over the endometrium to detect any abnormal
tissue that might be present. At a point on the left side just
above the internal os, the curette went through the uterine wall
without the least resistance. Immediately there was a gush of
blood which continued to flow freely. Not being able to appre-
ciate the situation, and the condition seeming to be one of grave
proportions, I at once proceeded to open the abdomen, the patient
having been previously prepared for a laparotomy. I found
the uterus normal in size and consistency and practically free
from adhesion. But the fullness on the left side proved to be a
mass of enlarged veins. They were massed so closely as to
constrict somewhat the movements of the uterus. They were
very much crowded together in the wall of the uterus as well as in
the broad ligament. The point of the closest contact seemed to
be at the point of the perforation. While doing the hysterec-
tomy the position of the perforation was easily seen, and that it
extended into the venous mass was most plainly shown. This
demonstrated that the source of the hemorrhage was from the
varicose veins. My firm conviction is that the perforation was
due to the degeneration produced by the varicosity. A careful
examination was made of many sections taken from dififerent
parts of the body and cervix. The cervix and the region of
the perforation were found to be free from malignancy, while
the fundus proper showed unmistakable evidences of malignancy.

I wish to quote from a few of our most eminent authors, giving
their ideas as to the slowness of the growth and the importance of
an early diagnosis. S. J. Cameron, London Lancet, 1905, says,
"Carcinoma in the body of the uterus has an undoubted tendency
to form in fibromyomatous uteri not from the tumor, but from
the uterus itself." In most of the pathological specimens
examined by him the growth has been diffuse. This was prob-
ably due to the fact that the patient had delayed too long in
seeking relief. It is difficult to distinguish adenocarcinoma
from these cases. Pain is a fairly early symptom in carcinoma



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478 BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS.

of the body of the uterus, but cases are not infrequent where
pain is absent until the growth is far advanced.

Thos. S. Cullen, 1900, reports the following case: Patient
aged thirty, pain in the lower left abdomen, extending into the
leg. The ovary was removed and the uterus suspended. She
left the hospital much improved. She was readmitted one year
later complaining of uterine hemorrhage. A curettage was
performed and the scrapings revealed the presence of adeno-
carcinoma. The patient refused operation and left the hospital.
She was readmitted seven months later and a hysterectomy done.
An examination was made of the uterus and appendages. The
squamous epithelium of the cervix was unaltered. The uterine
mucosa was practically normal, except some glandular hyper-
trophy. A diagnosis of adenocarcinoma was made. The under-
lying muscles were only slightly involved. Sections taken
through the outer part of the wall showed no pathological
change. This case shows clearly the slowness with which adeno-
carcinoma of the uterine body may advance.

A. Mottte, of Paris, 1904, says, *'The cancers of the body of the
uterus, although pathologically identical with these of the cer-
vical canal, are differentiated by the slowness of their evolution
and, in consequence, by their benignity."

H. Banga reports a case in the American Gynecological and
Obstetrical Journal, of 1899, as follows: Patient's age, forty-five,
irregular vaginal discharge of blood. An examination showed
no enlargement of the uterus; there were no nodules; the body
was soft and the os, to all appearances was healthy. Exami-
nation being impossible, curettage was decided upon. A diag-
nosis made from the scrapings showed glandular hypertrophy of
the mucous membrane with no signs of malignancy. An exami-
nation two months later showed no change. Bleeding still
continued, making us believe that malignancy must exist. There
was no pain felt at any time by the patient. Hysterectomy was
advised and done, and a careful examination was made from
sections taken from all parts of the uterus, and malignancy
found in the fundus, diagnosed as adenocarcinoma.

Beyea reports a case in the Amer. Jour. Obst. in 1896. The
patient was thirty -eight years of age; the only symptom was
hemorrhage from the uterus. Hysterectomy was advised and
performed. Microscopical examination was made of sections
taken from the cervix and body of the uterus. Malignant adenom-
atous changes were found in the corporeal endometrium, while
the cervix was perfectly normal, except a condition of cervical
endometritis.

Offergeld, in ** Archives of Gynecology," 1906, reports a case:
Patient was fifty-four years of age. Her only complaint was
a copious bloody discharge from the uterus. She complained
of no pain. A curettage discovered a glandular endometritis



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BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS. 479

with some suspicious places. Four weeks later a complete
hysterectomy was done. The uterus was enlarged to the size of
a fist, and the cavity was filled with a bleeding tumor mass.
The parametrium was free. A microscopical examination showed
the usual picture of chronic metritis with numerous newgrowths
of connective tissue. In the mucous membrane the glandular
formation was insignificant. Farther on the tissue was pene-
trated by carcinomatous cells. Diagnosed as adenocarcinoma
of the fundus.

A case reported in the BtUletin of Paris, in 1898, is as follows:

Patient's age, fifty-eight. She had a previous operation of a
uterine polyp that had been easy of removal and favorable. The
discharges, bloody and leucorrheal, did not cease as expected, and
the patient came again for examination. On examination, no ade-
quate cause could be discovered for the metrorrhagias, but there
was a suspicion that the discharges indicated a form of vegetat-
ing polyp that had escaped the previous examination. Curett-
age was performed. A small mass was expelled from the uterus
the size of a hazel-nut; this showed the presence of rows of epithe-
lium in a gangrenous tissue. Hysterectomy was performed, and
on examination the body of the uterus was found filled with
growths of whose malignancy there could be no doubt. Ana-
tomically, the cancer had not passed the isthmus, but was con-
fined to the body of the organ. The size of the uterus was
normal. The tumor represented a type of latent evolution.
Without the discharge its presence would not have been suspected.

In short, the absence of pain and the normal size of the uterus
would have prevented the patient from benefiting by any inter-
vention, if the discharge had not sounded the alarm and the
microscope allowed the correct diagnosis.

I have cited the foregoing cases, from various noted patholo-
gists of different parts of the world, to show that they, too, would
advise hysterectomy with seeming masked symptoms in these
cases. There are three symptoms that are to be looked for:
profuse leucorrhea, hemorrhage, and pain. The later in life,
the more grave these symptoms are considered, but the disease is
not confined to the aged alone. It is not necessarily true that
we must have all these symptoms in every case, for pain may be
absent entirely. Leucorrhea is the earliest symptom to be
looked for, and this, if profuse, is sufficient alone sometimes as an
early symptom. This latter symptom should always be regarded
as suspicious after menopause.

If there exists a persistent metrorrhagia a curettage should be
done for diagnostic purposes. It should be thoroughly done, as
if for a cure of the symptoms. A searching microscopical exami-
nation should then be made of the scrapings. If the condition



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480 BALLARD: PRIMARY ADENOCARCINOMA OF THE UTERUS.

be only one of fungoid endometritis, from which a difiFerential
diagnosis cannot be made, it will more than likely result in a
relief of the symptoms. If the examinations do not show malig-
nancy, and the symptoms continue unabating, then advise the
radical procedure. A thorough microscopical examination of
many of the sections taken from various parts of the uterus
should be made. You will usually be rewarded for your extra
work by finding the cause of the trouble to be a latent or begin-
ning malignancy.

I might report many more cases of my own and other operators,
but these given will suffice to make clear the slowness of the
growth in the body of the uterus, and the importance of our more
closely observing the few symptoms that do present themselves
in order to make an early diagnosis and enable us to act in a
radical way in time to make a favorable prognosis possible.

In the microscopical drawings I have tried to select those
fields that would demonstrate most clearly the different stages of
the progress of the disease, from the earliest disturbances of the



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 48 of 109)