Medical reprints with original essays : home, foreign, and colonial, illustrated.

Date:
1897
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Licence: Public Domain Mark

Credit: Medical reprints with original essays : home, foreign, and colonial, illustrated. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    Ffirst8 is very extreme in his suggestions for treatment. Although he regards glandular hyperplasia as benign, he does not think it is wise to be content with curetting, but “ to strive for excision, as the new formation inclines to malignant degeneration.” C. Ruge9 uses the terms benign and malignant adenoma. By the former he understands simple glandular hyperplasia. “ In malignant adenoma there are changes in the entire uterine tissue. Metastases occur in other organs. Solid cell processes invade the deeper parts to a greater extent than is common in cancer.” These last changes are certainly those of true cancer. Lander and Abel10 use the term simple adenoma, meaning glandular hyperplasia, in contradistinction to malignant adenoma. They consider the amount of relatively unchanged interglandular tissue as the best guide in distinguishing the two forms. Ziegler” considers adenomata of mucous membrane in general as not sharply differing from cancer. Williams12 thinks adenoma in the uterus is probably always malignant. J. Veit13 says: “ There is a gradual transition from adenoma to cancer.” Cushing14 describes malignant adenoma of the uterus as “ an adenomatous thickening of the mucous membrane of the body of the uterus in elderly women, which finally degenerates into carcinoma.” The majority of writers, then, classify the marked cases of chronic endometritis with glandular hyperplasia among the adenomata. So long as the reproduction of the glands con- forms perfectly to the normal gland type, they speak of them as benign. When the numerical increase becomes excessive, and the epithelium tends to form in several layers ; when the interglandular tissue becomes scanty, and the tissue consists almost entirely of new-formed glands, and inroads are made into neighbouring tissues, they are called malignant. Further- more, the latter form of lesion is generally considered as the initial stage of cancer. In other words, simply hypertrophy and hyperplasia are not distinguished from the changes exist- ing in a well-defined tumour. Many writers, too, wrongly speak of malignant degeneration of a tumour, using the term degeneration in the same way that it is used in speaking of fatty or amyloid degeneration. Before taking up the four cases which the present writer has to offer as examples of malignant adenoma of the uterus, it was thought that it might be useful to give a general description of the curettings from nine cases of well-marked adenomatous hyperplasia. ''-'.vf- y 'K$*£•>!' dh '„*• i-'5* Fro. 1. In these nine cases of adenomatous hyperplasia, the in- crease in the size and the number of the glands was very well marked. The epithelium, for the most part, consisted of one layer resting on a distinct membrana propria. The stroma was considerable in amount and showed in some cases the changes of a simple exudative inflammation, while in others /here was the formation of new connective tissue. In other vords, the glandular hyperplasia seemed to be simply a part )f or a result of an ordinary chronic inflammation of the nucous membrane. Fig. 1 represents the condition in one of hese cases. ' € Zeit.srh riftf. Geburts. u, Gyn,5 xiv, p. 352, 1SS7. ‘ y Arehiv fiir Gyn.,xxxii, p. 487. 10 Arehivfiir Gyn., xxxiv,p. 16?. • 41 Ziegler. Lehrbuch-dei’speciEUen pathologischen Anatom>e, ’ %} 42 'VVilliarins. Crtricer of the Uterus. ;4;{ ZADchriftf. Geburts. u. Gyn., vo\ i, 1887, p. 1S9. oj’ Gyn. and Peediatry, May, 1891, p. 458. The ages of these patients from which the curettings were taken range from twenty-eight to forty-seven. The most marked condition was in a patient of thirty-eight years. Five of the cases had been curetted before with relief for from six months to two years. Two of the cases were thought to be malignant clinically, because of their loss of flesh and poor general condition. This cachexia could readily be ascribed to tile severe and protracted hemorrhages from which they had suffered. There were no appearances in these curettings which would warrant their classification among the neoplasms or suggest malignancy. The possibility of their future develop- ment into a malignant new growth can not be denied, but in the writer’s experience thorough curetting and appropriate after-treatment cure most cases of chronic endometritis with glandular hyperplasia. The curettings of two other cases, representing a more serious condition, have been very recently examined. In both of them the larger part of the curettings show simply a glandular hyperplasia; but there are a few places in one case where there is an excessive numerical increase of glands and proliferation of the lining epithelium into several layers, with a very small amount of intervening stroma. In all parts a severe exudative inflammation is in progress, leucocytes almost filling the lumina of the glands. We have here, then, a beginning malignant adenoma. In a few places in the other case there are alveoli filled with regularly arranged epithelium, and with no trace of normal gland structure left. There is no exudative inflammation present, and glandular hyperplasia is not so well marked. In this case there is certainly a beginning carcinoma. In both of these latter cases we have a simple benign process coexisting with a certain amount of excessive and lawless growth. We might interpret these changes as repre- senting different steps of the same process if we knew certainly that they dal not begin independently of each other. Fig. 2 represents a section of some curettings showing coexistence of adenoma and carcinoma. On the left are seen the enlarged glands lying close together. The epithelium has proliferated into several layers, but the gland type is preserved. On the right the alveoli are completely filled with epithelium, and we have true cancer. In contrast to the .previous conditions, the writer wishes to describe four cases of well-marked malignant adenoma. Case 1.—Patient, forty-eight years of age, had had three children, the last one fourteen years ago. Her menstruation had always been regular until two years and a half before admission to the hospital. Since then she has flowed almost continuously, and has lost flesh rapidly for seven months, and during the last four months has suffered from severe pains in the lower part of abdomen and back. Examination.—Patient is pale and thin. Palpation reveals a hard, smooth tumour in the median line of the lower part of ab lomen, reaching to the umbilicus above. Bimanual examin ation shows the tumour to be an enlarged uterus. The cervix is short, soft, and the external os admits one finger. Behind and to the left of the uterus is a hard, immovable tumour, which with the uterus completely fills the pelvis and lower part of abdomen. ,• . t Patient was curetted, and, a large amount of fleshy material having been scraped out, the entire uterus and tumour behind, with an indurated portion of the vaginal wall, were removed through the abdomen. The uterus externally resembles in its form one at full term of pregnancy, its cervix having almost disappeared. It measures from fundus to external os seven inches, and across the fundus between the tubal openings four