Papillary Cancer of the Body of the Uterus ; Absence of Cardinal Symptoms BY GEORGE ERETY SHOEMAKER, M.D. Gynecologist to the Methodist Hospital of Philadelphia REPRINTED FROM The American Journal of Obstetrics Vol. XXXV. No. 4, 1897. NEW YORK WILLIAM WOOD & COMPANY, PUBLISHERS 1897 PAPILLARY CANCER OF THE BODY OF THE UTERUS; ABSENCE OF CARDINAL SYMPTOMS? The uterus shown in the accompanying illustration demon- strates well the extent of destructive infiltration by malignant disease of the body of that organ which may take place with- out presenting those symptoms which are frequently considered essential to a diagnosis of malignancy. In contrast with can- cerous disease of the cervix, when the body is primarily affected the classical group of symptoms, pain, odor, watery discharge with flocculi, hemorrhage, and cachexia, either do not appear at all, or only in the final stages long after all chance for helpful surgery is gone. Particularly in malignant adenoma of the endometrium abnormal bleeding may be the only symptom, and expert examination may be negative unless assisted by the curette and the microscope. Fortunately these microscopical examinations are becoming more satisfactory, and in the future the diagnosis of the benign nature of adenomatous growths of the endometrium will less frequently give a false sense of se- curity. That seems a bold statement, however, of W. J. Sin- clair,' who says: ' ' Any post-climacteric polypus or fungus of the endometrium of the body of the uterus is adenoma malignum." Mrs. X., aged 63, was sent to me by Dr. J. R. Bryan. Three children, youngest aged 20. No menopause. She was large, active, well nourished, intelligent, the wife of a broker. She claimed to weigh more and to feel better than a year before. Not very anemic, slightly yellow, but for several years there had been attacks of liver disorder with occasional jaundice. There had been no pain and no odor. Bleeding was the only marked symptom, but this was decided. The menses had never stopped. About the age of 45 they became irregular, but always appeared several times a year for the eighteen years 1 Read before the Section on Gynecology of the College of Physicians of Philadelphia, January 21st, 1897. 2 " System of Gynecology," Allbut and Playfair, 1896. p. 734. 2 SHOEMAKER: PAPILLARY CANCER succeeding, amount gradually increasing, with occasional sharp hemorrhage. For the past six months almost daily discharge of blood. A little odorless, watery discharge at times. Urina- tion normal. Through the speculum the vaginal cervix ap- peared normal, the os not enlarged or excavated, but the small visible portion of the cervical canal was dusky red. Diagnosis of malignant disease of the body was made by bimanual touch, which showed a symmetrically enlarged, retro verted, soft fundus, while the lower half of the uterus was extremely rigid, Papillary cancer of uterine body. lacking the normal resiliency of muscular tissue when pressed between the fingers of the two hands. There were no nodules. The finger tip upon the os, which was small, felt a sharp edge all around the opening. A suspicious rigidity about this edge made the os feel as though punched out. This sharp edge may be felt where a polypus lies in the uterine canal, but it is then never rigid. A gentle attempt to test downward mobility with a tenaculum brought on bleeding which required a tampon for its control. Three days later vaginal hysterectomy by ligation was done at the Methodist Hospital. There were absolutely OF THE BODY OF THE UTERUS. 3 no adhesions to the uterus, but the tubes and ovaries by adhe- sions high up, supposed from the history to be post-puerperal, interfered with the ready drawing-down of the uterus. The space between the bladder wall high up, and friable, infiltrated uterine tissue was very narrow, but the separation was com- pleted without accident. No infiltration could be felt outside the uterine body. The recovery from operation has been un- eventful. After removal the uterus measured in length 20.5 centimetres. Fundus, from side to side, 6 centimetres ; from before back, 4.75 centimetres. The photograph of the organ, split open in front after re- moval, shows the excavation, which had occurred inside the uterus down to the level of the external os. The os itself, however, is not shown in its natural condition, having been burned out with the cautery at the beginning of the operation, then packed with gauze and sewed up to protect the field from soiling. The irregular masses near the fundus were exceed- ingly soft, almost brain-like in consistence. The lower seg- ment of the uterus was quite hard from infiltration. The peri- toneum over the uterus was everywhere intact. The following is the report of the pathologist, Dr. Henry W. Cattell : Macroscopically the tumor shows numerous elevations and depressions originating from the mucous membrane. There are points from which bleeding has occurred ; some of the elevations are merely attached by shreds and could have been readily removed by the curette. The question naturally arises how far these scrapings would have led to a correct diagnosis of the case. The majority of these are papillary in their character, and it is only at their point of attachment with the muscular tissue that an undoubted cancerous change is noted by the microscope. There has also been considerable irritation of an inflammatory nature, as is seen by large collec- tions of round cells. The tumor has started as a benign papil- lary adenoma, perhaps springing from some placental rem- nants and being of slow growth until the later malignant changes noted above have started. The section studied was from tissue removed at A, including the entire thickness of the side of the uterine wall. It takes in the three fields of the benign adenomatous portion, the malignant portion, and the normal uterine wall. 3727 Chestnut street.